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Psychotherapy

2011, Vol. 48, No. 1, 2533

2011 American Psychological Association


0033-3204/11/$12.00 DOI: 10.1037/a0022060

This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Alliance in Couple and Family Therapy


Myrna L. Friedlander

Valentn Escudero

University at Albany/State University of New York

Universidad de La Coruna

Laurie Heatherington

Gary M. Diamond

Williams College

Ben Gurion University of the Negev

Couple and family therapy (CFT) is challenging because multiple interacting working alliances
develop simultaneously and are heavily influenced by preexisting family dynamics. An original
meta-analysis of 24 published CFT alliance-retention/outcome studies (k 17 family and 7 couple
studies; N 1,416 clients) showed a weighted aggregate r .26, z 8.13 ( p .005); 95% CI
.33, .20. This small-to-medium effect size is almost identical to that reported for individual adult
psychotherapy (Horvath Del Re, Fluckiger, & Symonds, this issue, pp. 9 16). Analysis of the 17
family studies (n 1,081 clients) showed a similar average weighted effect size (r .24; z 6.55,
p .005; 95% CI .30, .16), whereas the analysis of the 7 couple therapy studies (n 335 clients)
indicated r .37; z 6.16, p .005; 95% CI .48, .25. Tests of the null hypothesis of
homogeneity suggested unexplained variability in the alliance-outcome association in both treatment
formats. In this article we also summarize the most widely used alliance measures used in CFT
research, provide an extended clinical example, and describe patient contributions to the developing
alliance. Although few moderator or mediator studies have been conducted, the literature points to
three important alliance-related phenomena in CFT: the frequency of split or unbalanced
alliances, the importance of ensuring safety, and the need to foster a strong within-family sense of
purpose about the purpose, goals, and value of conjoint treatment. We conclude with a series of
therapeutic practices predicated on the research evidence.
Keywords: couple and family therapy, meta-analysis, alliance, therapy relationships

only do family members vary in the degree to which they form a


personal bond and agree with the psychotherapist about treatment
goals and tasks, but also each person observes, can report on, and
is influenced by how others in the family feel about the therapy
and by how the couple or family unit as a whole is responding to
what is taking place in treatment (Pinsof & Catherall, 1986). Thus,
from its first introduction into the literature, the CFT alliance was
described as unique, complex, and multilayered.
In this article, we define CFT alliances, summarize the major
observational and self-report measures, and offer an extended
clinical example. We then report the results of our original metaanalysis of the published CFT alliance-outcome studies, summarize what is known about the major moderators, mediators, and
client contributions to CFT alliances, and discuss the limitations of
the research and implications for clinical practice.

Although the salience of the working alliance in couple and


family therapy (CFT) was recognized over 20 years ago, it has
received far less theoretical and empirical attention than has the
alliance in individual psychotherapy. In their seminal work on CFT
alliances, Pinsof and Catherall (1986) took Bordins (1979) conceptualization of the alliance as a point of departure and applied
the goals, tasks, and bonds constructs to three interpersonal facets
of the alliance in family treatment (self-with-therapist, other-withtherapist, and group-with-therapist). The rationale was that not

Myrna L. Friedlander, Department of Educational and Counseling Psychology, University at Albany/State University of New York; Valentn Escudero,
Department of Psychology, Universidad de La Coruna; Laurie Heatherington,
Department of Psychology, Williams College; and Gary M. Diamond, Department of Psychology, Ben Gurion University of the Negev, Israel.
This article is adapted, by special permission of Oxford University
Press, from a chapter of the same title by the same authors in J.C. Norcross
(Ed.). (2011). Psychotherapy relationships that work (2nd ed.). New York:
Oxford University Press. The book project was co-sponsored by the APA
Division of Psychotherapy.
We are grateful to Cristina Muniz de la Pena for her valuable contribution to the meta-analysis, and to Gabriel Garza Sada, Hanna Seifert, and
Joshua Wilson for their assistance in the literature search.
Correspondence concerning this article should be addressed to Myrna L.
Friedlander, Ph.D., Department of Educational and Counseling Psychology, Education 220, University at Albany/SUNY, 1400 Washington Avenue, Albany, NY 12222. E-mail: mfriedlander@uamail.albany.edu

Definitions and Measures


Family members often seek psychotherapy as a last resort, when
the conflicts among them seem irreconcilable, and they often have
different motives and motivational levels for treatment. Even when
problems are jointly acknowledged, for example, We fight all the
time, therapy may not be seen as the solution, or individuals
goals may differ (You need to stop drinking vs. We need to be
a coupleits like were living parallel lives) (Friedlander,
Escudero, & Heatherington, 2006; Lambert, Skinner, & Friedlander,
in press). Consequently, family members willingness to engage in
25

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

26

FRIEDLANDER, ESCUDERO, HEATHERINGTON, AND DIAMOND

various treatment tasks may also differ (Why should we discuss


my drinking if you dont even want to stay married?). Certain
clients may feel like a therapy hostage (Come to therapy with me
or else . . .) or expect the clinician to take sides, particularly if the
problem is defined in zero-sum terms (to divorce or not, to relocate
or not).
CFT alliances develop simultaneously on an individual level
(self-with-therapist) and a group level (group-with-therapist). Just
as in individual therapy, alliances in CFT involve the creation of a
strong emotional bond as well as negotiation of goals and tasks
with the therapist. A unique characteristic of CFT, though, is that
at any point in treatment there are multiple alliances that interact
systemically (Pinsof, 1994). For example, the degree to which a
mother likes the psychotherapist and is engaged in the treatment
may have a facilitating (or hindering) effect on her sons
willingness to trust the therapist. The sons involvement also
depends on the mother-son bond and whether he agrees with his
mother about the nature of the problems, goals, or need for
treatment. Moreover, the family members degree of comfort
with each other affects each persons willingness to negotiate
goals with the others and with the therapist.
An important aspect of CFT alliances is the degree to which
family members feel safe and comfortable with each other in the
therapeutic context. The revelation of secrets and in-session exploration of conflicts are not easily left behind in the consulting
room at the end of the session. Family members go home together,
and therapy can only progress if they feel that the material discussed in-session is not used against them during the course of the
week. Breaches of safety can severely undermine a clients trust in
the therapist and the therapeutic process. Moreover, the degree of
safety felt by family members can change as new problems are
revealed and explored and as different family members join or
leave treatment (Beck, Friedlander, & Escudero, 2006). What feels
safe to the children when only their father is there, for example,
might feel quite unsafe when their stepmother is present. Likewise,
it may seem safer in couple therapy to discuss conflicts over
parenting than to explore expectations about intimacy or sexuality.
The conjoint nature of the treatment and ever-changing composition of sessions makes creating a safe environment both complicated and critical.
A related construct is the group aspect of the alliance, which has
alternately been conceptualized as allegiance (Symonds & Horvath, 2004), within-family alliance (Pinsof, 1994), and shared
sense of purpose (Friedlander, Escudero, & Heatherington, et al.,
2006). This construct refers not only to a willingness to collaborate
in treatment but also to a strong emotional bond between and
among family members. The within-family alliance has more to do
with family members thoughts, feelings, and behavior toward one
another than it does with any one persons alliance with the
therapist considered in isolation. Moreover, the within-family alliance develops simultaneously and in interaction with all of the
individual alliances. Research shows that family members often
see their personal relationships with the therapist differently from
their allegiance with each other (e.g., Beck et al., 2006; Friedlander, Lambert, Escudero, & Cragun, 2008; Lambert et al., in
press). For this reason, a complete picture of the alliance requires
some accounting of how well the family works together in therapy
as well as how similarly individuals feel about the therapist. When
alliances are split (Heatherington & Friedlander, 1990; Pinsof &

Catherall, 1986) or unbalanced (Robbins, Turner, Alexander, &


Perez, 2003), at least one family member has a stronger bond with
the therapist than do other family members. In CFT, split alliances
occur frequently and vary in severity (Heatherington & Friedlander, 1990; Mamodhoussen, Wright, Tremblay, & PoitrasWright, 2005; Muniz de la Pena, Friedlander, & Escudero, 2009).
In family therapy, we might expect the therapist to have a greater
connection with the parents than with the adolescents; while this
pattern has been reported in several studies, it has also been found
that many adolescents feel closer to the therapist than do the
parents (Muniz de la Pena et al., 2009).
The most widely used self-report measures are the Couple
Therapy Alliance Scale (CTAS; Pinsof & Catherall, 1986) and the
Family Therapy Alliance Scale (FTAS) and their shorter versions,
the CTAS-r and FTAS-r (Pinsof, Zinbarg, & Knobloch-Fedders,
2008). Like the couple version of the Working Alliance Inventory
(WAI-Co; Symonds & Horvath, 2004), the CTAS and FTAS
reflect Bordins (1979) concept of goals, tasks, and bonds, but they
also reflect the within-family alliance. CFT alliances have also
been studied using the Vanderbilt Therapeutic Alliance Scale, an
observer scale that was revised for CFT and pared down empirically to five patient contribution items (Shelef & Diamond, 2008).
Using the VTAS-R, raters judge each clients overall behavior and
therapist-client interactions over an entire session.
Only one measure of the alliance includes the element of safety.
In the System for Observing Family Therapy Alliances (SOFTA;
Friedlander et al., 2006; Friedlander, Escudero et al., 2006) or
Sistema de la Observacion de la Alianza en Terapia Familiar
(SOATIF), safety is one of four alliance dimensions. In brief,
Safety within the Therapeutic System reflects each clients degree
of comfort taking risks, being vulnerable, and exploring conflicts
with a therapist and other family members, Engagement in the
Therapeutic Process reflects Bordins (1979) agreement with the
therapist on tasks and goals, Emotional Connection with the Therapist is similar to Bordins concept of client-therapist bond, and
Shared Sense of Purpose within the Family refers to productive
family collaboration (the within-family alliance). The transtheoretical SOFTA contains observational (SOFTA-o; Friedlander,
Escudero, & Heatherington, 2006; Friedlander, Escudero, & Horvath, et al. 2006) and self-report (SOFTA-s; Friedlander, Escudero,
& Heatherington, 2006; Friedlander, Lambert, Escudero et al., 2008a;
Lambert & Friedlander, 2008) measures from both client and therapist
perspectives. Using the SOFTA-o, trained raters make a global rating
for each alliance dimension based on the frequency and clinical
meaningfulness of specific positive, for example, Client introduces a
problem for discussion (Engagement), and negative behaviors, for
example, Family members try to align with the therapist against each
other (Shared Sense of Purpose).

Clinical Example
A middle-aged couple brought their reluctant 15-year-old son
and 13-year-old daughter to psychotherapy. The girl, who exhibited anxiety and an eating disorder (only at home), refused to speak
in the session, as did the boy, who had vandalized a neighbors car
and was failing in school. While the parents barely glanced at each
other, both adamantly insisted that their children were in desperate
need of help. Thus ended the first session, which clearly evidenced

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SPECIAL ISSUE: COUPLE AND FAMILY THERAPY ALLIANCES

a lack of safety all around and an exceedingly poor within-family


alliance.
Because it was obvious that conjoint sessions with the four
family members would not be productive at this stage of treatment,
the therapist proposed holding the next two sessions with the teens
and the parents separately. Indeed, this seemed to be the only
arrangement that could provide even a modest amount of safety. In
the childrens session, the boy willingly expressed concern about
his sister, but he cavalierly dismissed his own problems. For her
part, the girl denied being anxious or having eating problems and,
instead, complained about how her brother constantly annoyed her.
As siblings, they collaborated minimally, each one only willing to
talk about the others problems. When asked about relations with
their parents, both teens remained silent. Finally, the son asked if
the therapist thought he could help their parents, but he refused to
clarify the basis for this request. Notably, the alliance seemed split:
The boy was visibly more involved and connected with the (male)
therapist than was his sister, whose sense of safety appeared to be
quite fragile. In their conjoint session, mother and father demonstrated even greater dis-ease with each other. Not only did they not
make eye contact or confer with one another, but they sat on either
end of the couch, their bodies positioned in opposing directions.
Although both parents cooperatively described the childrens problems, they refused to discuss their own relationship. Finally, the
husband haltingly explained that after something happened, he
and his wife had agreed that the marriage was finished. This
emotional divorce was unknown to the children, however. Because neither parent was willing to leave the home, they planned
to continue living together until both children grew up and moved
out. Neither client was willing to consider couples work, as they
were in agreement that their marriage was a lost cause. They
were, however, willing to come for sessions if it would help their
children.
It was interesting that within each subsystem there was a shared
sense of purpose, at least about why they would continue coming
to therapy: The children agreed to be seen so that the therapist
would help their parents, and the parents agreed to come in order
to help their children. Given this curious arrangement and everyones clear fear of taking emotional risks, the therapist continued
to see each subsystem weekly. He found it relatively easier to
develop a personal bond with the son and the mother. By working
hard to enhance his connection with the daughter and father, the
therapist gradually became a trusted figure, and slowly everyone
began to engage more freely in the therapeutic work. Because the
adolescents adamantly refused to acknowledge their own problems
and were clearly protecting their parentsnever criticizing them
or even acknowledging their parents overt hostilitythe therapist
focused solely on improving the sibling bond. In one homework
assignment, for example, the girl was asked to choose a set of
digital family photos that held happy memories for her, and her
brother was asked to arrange these pictures into a slideshow that he
would set to music.
As brother and sister began fighting less at home and cautiously
started to enjoy each others company, both parents began to trust
the therapist more. However, they rarely looked at one another in
session, and the chasm between them remained as deep as ever. In
week 5, the therapist made some strategic moves with the parents.
Focusing first on the within-system alliance, he praised their
mutual dedication to their children, pointing out how they were

27

both willing to sacrifice [their] personal happiness to keep the


family together. For the first time, the spouses looked at and
spoke directly to one another. When the husband made a joke that
his wife smiled at, the therapist commented that they both seemed
to be experiencing deep hurts that they were afraid to express.
He said that he wanted it to see if there was another way for [their
marital] relationship to improve, if only to keep on helping the
children.
The mother, who seemed to trust the therapist a great deal,
admitted thinking that the children were reacting to the emotional divorce. Moving closer to her, the therapist softly commented that, As a parent myself, I know its extremely hard to
realize that something Ive done has hurt my children. The mother
responded with tears, and at the end of the session admitted that the
children deserved to be told about the status of the marriage. The
husband agreed, albeit reluctantly. The parents chose to reveal
the secret at home rather than in a conjoint session. In their next
session (alone) with the therapist, the teens no longer felt the need
to protect their parents. They responded positively to the therapists empathic response to their expressions of resentment and
sadness. When the daughter burst out, But were not a real
family!, the therapist replied by proposing a new shared sense of
purpose, that is, common goal: I disagree. Both of your parents
care for you and want the best for you, and both of you feel the
same for your parents. Im sure you can learn to work together so
that everyone has a happier life. Over the next month, the teens
pushed their parents into committing to couples therapy, with the
goal of either working out their differences or deciding to separate.
Although the sons grades in school did not improve substantially,
he had no further delinquent offenses. The daughter remained
highly stressed but ate normally and began spending more time
with friends.
This case illustrates how an alliance-empowering approach can
potentially repair seriously broken within-family attachments. By
strategically focusing on different alliances and different aspects of
each alliance, this therapist moved a stalled treatment forward. He
began by separating the parents and children to enhance safety and
negotiate different problem definitions and goals within each subsystem. With the adolescents, the therapist relied heavily on five
interventions that have been shown to improve poor alliances with
teens (Diamond, Liddle, Hogue, & Dakof, 1999): He emphasized
trust, honesty, and confidentiality; explained the importance of
collaborating in therapy; defined meaningful goals for each child;
and, most importantly, presented himself as an ally in the one thing
the children agreed on helping their parents. Then, by encouraging engagement in therapy tasks through his personal bond with
each person, the therapist eventually redefined the familys problem and the treatment goals in a way that was both respectful and
challenging. The success of this process goal, to create a withinfamily shared sense of purpose, seemed largely due to the therapists attending to and emphasizing the strong parent child bonds.

Meta-Analytic Review
Table 1 summarizes 24 studies in which CFT alliances, selfreported and observed, were used to predict treatment retention,
improvement midtreatment, and/or final outcomes (see Friedlander, Escudero, Heatherington, & Diamond, in press, for all
references). The studies were located by electronic searching

couple
family
family

EFT
FS
MDFT

EcoS

EcoS

EFT
PE
IPCT
FBT
IPCT

FS
CBT

FFT
MDFT
BSFT
MDFT

MDFT
PE

NS

Johnson et al. (2006)

Johnson & Ketring (2006)

Johnson & Talitman (1997)


Kazdin et al. (2005)
Knobloch-Fedders et al. (2007)
Pereira et al. (2006)
Pinsof et al. (2008)

Quinn et al. (1997)


Raytek et al. (1999)

Robbins et al. (2003)


Robbins et al. (2006)
Robbins et al. (2008)
Shelef et al. (2005)

Shelef & Diamond (2008)


Smerud & Rosenfarb (2008)

Symonds & Horvath (2004)

O
O

O
O
O
C,O

C
O

C
T, C
C
O
C

C
C, T
O

O
O
O

C, T

Rater

(Bond)

(tasks)

WAI-Co

VTAS-R
SOFTA

VTAS-R
VTAS-R
VTAS-R
WAI

FTAS
VTAS-R

CTAS
WAI,
CTAS
CTAS
WAI
CTAS-R

FTAS

FTAS

CTAS
WAI
VTAS-R

SOFTA
VTAS-R
SOFTA

WAI

CTAS

Measure

Alliance

E,L
L

E
E
E
E

E
E

E
E,L
E,L
E,L
E,L

E
E,L
E

E,L
E
E

Time

Enright Forgiveness Inventory


Youth Symptom Self-report
Child Behavior Checklist (internalizing, externalizing),
Timeline Follow-Back interview for substance use
Outcome Questionnaire, Inventory of Parent and Peer
Attachment
Outcome Questionnaire 45.2-Symptom Distress subscale,
Conflict Tactics Scale-Physical Aggression Subscale
Dyadic Adjustment Scale, Miller Social Intimacy Scale
Treatment Improvement Scale, Marital Satisfaction Scale
Marital Satisfaction Inventory Revised
Eating Disorders Examination
COMPASS Treatment Assessment System, Marital
Satisfaction Inventory Revised
Goal achievement and expectation of maintenance
Attrition status (completers, partial completers, vs. early
dropouts)
Completion vs. dropout
Completion vs. dropout
Completion vs. dropout
Global Appraisal of Individual Needs, Substance
Problem Index
Completion vs. dropout, days of cannabis use
Brief Psychiatric Rating Scale, Social Adjustment ScaleII, days until first re-hospitalization, days until first
use of rescue medication, Patient Rejection Scale
Marital Satisfaction Scale (female)

Perceived therapeutic improvement


Completion vs. dropout
Perceived improvement-so-far

Dyadic Adjustment Scale, Marital Happiness Scale,


Potential Problem Checklist
Psychological Maltreatment of Women Scale, Modified
Conflict Tactics Scale

Outcome Measure

.37

.41
.54

.29
.35
.36
.24

.53
.37

.54
.32
.39
.32
.31

.10

.46

.35
.33
.05

.22
.25
.35

.53

.43

Wt. Ave. r

22.4

45
28

34
30
31
59

19
66

23
49
37
31.4
80

430

32

40
36.7
44

68
86
33

70

63

Ave. N

Overall effect size

Note. N refers to the average sample size for the various correlations used in the within-study meta-analysis, i.e., not the N in the entire study. CSP Couple Survival Program; CBT
Cognitive-Behavioral Therapy; PE Psycho-educative; BFT Brief Family Therapy; FFT Functional Family Therapy; FS Family Systems; EFT Emotional-Focused Therapy; MDFT
Multidimensional Family Therapy; EcoS Ecosystemic Therapy; FBT Family-Based Therapy; IPCT Integrative Problem Centered Therapy; BMT Behavioral Marital Therapy; BSFT Brief
Strategic Family Therapy; NS not specified. C client self-report; T therapist self-report; O external observer. CTAS Couple Therapy Alliance Scale (Pinsof & Catherall, 1986); CTAS-r
Couple Therapy Alliance Scale-Revised (Pinsof et al., 2008); FTAS Family Therapy Alliance Scale (Pinsof & Catherall, 1986); SOFTA-o System for Observing Family Therapy Alliances-observer
(Friedlander, Escudero, & Heatherington, 2006); VTAS-R Vanderbilt Therapeutic Alliance Scale-Revised (Diamond et al., 1996); WAI Working Alliance Inventory (Horvath & Greenberg, 1986);
WAI-Co Working Alliance Inventory - couple (Symonds & Horvath, 2004); E early; L late. All studies in this table are referenced in Friedlander et al. (in press).

couple

family
family

family
family
family
family

family
marital

couple
family
couple
family
couple

family, home based

family, home based

family
family
family

couples group

BFT
FFT
FS

CBT, PE

Brown & OLeary (2000)

couples group

Format

Escudero, Friedlander, Varela,


& Abascal (2008)
Flicker et al. (2008)
Friedlander, Lambert, & Muniz
de la Pena et al. (2008b)
Greenberg et al. (2010)
Hawley & Garland (2008)
Hogue et al. (2006)

CSP

Therapy model

Bourgeois et al. (1990)

Study

Treatment

Table 1
Summary of Alliance-Outcome Studies in CFT

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28
FRIEDLANDER, ESCUDERO, HEATHERINGTON, AND DIAMOND

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SPECIAL ISSUE: COUPLE AND FAMILY THERAPY ALLIANCES

(PsycInfo, PubMed, Social Sciences Citation Index) and crossreferencing of key articles. Unpublished dissertations were excluded, as were analogue studies, non-English articles, and studies
that did not use validated alliance measures.
Seven of the 24 studies were couples therapy (two of which
were conducted in groups), and the remaining 17 were family
studies in which at least a portion of the treatment was conducted
conjointly. The total number of clients in the 24 studies is 1,461.
Studies examined treatment-as usual as well as specifically defined
approaches, for example, cognitive behavioral therapy, functional
family therapy, emotion-focused therapy, psycho-educational family therapy. Most treatments were fewer than 20 sessions, and the
majority (65%) described the therapy as manualized treatment,
although only a few provided information about treatment integrity.
The target problems ranged from parent-adolescent communication difficulties to substance abuse, child abuse or neglect, and
schizophrenia; many of the studies identified the clients problems
generally. The instruments and methods used to evaluate outcome
reflect the variability in problems treated. Roughly 50% of the studies
used an observational methodology. Most evaluated the alliance early
in the therapy, and only a few studies assessed the alliance at different
stages of treatment (early, middle and late). The observational instruments were primarily the SOFTA-o and the VTAS; the WAI and
CTAS/FTAS were most often used to measure self-reported alliance.
Five of the 24 studies did not measure client outcome but rather only
explored associations between alliance and treatment retention.
For the meta-analysis of correlation coefficients, we used the
recommendations and computation program of Diener, Hilsenroth,
and Weinberger (2009), which are based on Hunter and Schmidts
(1990) random-effects approach. For studies that reported statistics
other than correlation coefficients (e.g., a t test to compare the
alliance in families that completed therapy vs. those that dropped
out), we calculated the corresponding conversions to r.
Because of the complex structure of alliance in CFT (multiple
participants generating multiple levels of analysis), most of the 24
studies reported more than a single alliance-outcome correlation.
In these cases, we calculated a meta-analytic statistic within each
study in order to maintain the statistical assumption of independence. Thus, the effect sizes listed in the far right column of Table
1 were calculated from aggregated correlations within each study.
The weighted average effect size for the 24 studies was r .26,
z 8.13 ( p.005), with a 95% confidence interval of .33 and .20,
indicating that the association between alliance and outcome was
statistically significant and accounted for a substantial proportion
of variance in CFT retention and/or outcome. According to conventional benchmarks, an r of .26 (d .53) is a small-to-medium
effect size in the behavioral sciences; this value is quite similar to
the r .275 reported by Horvath, Del Re, Fluckiger, and Symonds
(this issue, pp. 9 16) on the alliance in individual therapy.

Moderators and Mediators


Evident differences in the designs, measures, therapy formats,
and problems treated in the 24 studies made it essential to test for
variables that may moderate the average effect size. An examination of the homogeneity of various subsamples, 2 43.52, p
.005, indicated that the null hypothesis of homogeneity was rejected; that is, there was unaccounted for variability among the

29

effects produced by the various studies. Consequently, we explored one moderator (treatment format) that might explain the
heterogeneity by computing separate analyses with two subsamples (family and couple therapy).
Analysis of the 17 family studies (n 1,081 clients) showed a
average weighted effect size similar to what was found for the
entire sample (r .24; z 6.55, p .005; 95% CI .30, .16),
and the null hypothesis of homogeneity was also rejected (2
27.77, p .05). In other words, the group of studies with a family
therapy format had significant unexplained variability in the relation between alliance and outcome. The analysis of the seven
couple therapy studies (n 335 clients) showed a slight difference, whereas the average weighted effect size was similar (r
.37; z 6.16, p .005; 95% CI .48, .25). Although the
homogeneity in this subsample was somewhat higher (2 11.08,
p .08) in this subsample, two of the seven studies used a group
couple format. For this reason, we did not conclude that the
alliance-outcome association in couple therapy was more homogeneous than its counterpart in family therapy.
Divergences in effect sizes across the outcome studies, as well
as complex findings within these studies, raise questions about the
circumstances under which the alliance figures more or less
strongly in outcomes. Because few direct tests of moderators and
mediators were conducted in the original studies, a meta-analysis
was not possible. In this section, we summarize what is known and
has been suggested about moderators and mediators of the
alliance-outcome relation in CFT.

Alliance and Treatment Retention


Good outcomes depend on attendance, and retention in family
therapy is challenging. For this reason, there has been significant
work in CFT on strategies for engaging and retaining families,
especially families with drug-using adolescents (cf. Szapoznick et
al., 1988). Regarding retention, the only clear moderator is family
roleparent, spouse, child. First, we note that the composite index
of CFT alliance, that is, an average of all family members alliances, is not predictive of retention (or outcome). Rather, more
nuanced indices of alliance matter: (a) the interplay of each individual family members alliance with the therapist, and (b) unbalanced alliances, in various permutations (mother-child, fathermother, etc.). For example, with adolescents who have
externalizing problems (Shelef & Diamond, 2008) or anorexia
(Pereira, Lock, & Oggins, 2006), research has found that the
parents (but not the youths) alliances predicted treatment completion. In studies with externalizing adolescents (Robbins et al.,
2008), both the childrens and the parents alliances with the
therapist discriminated dropout from completer families, and unbalanced alliances tend to be negatively related to retention, and
this relation is also moderated in complex ways by family role
(Robbins et al., 2003; Robbins et al., 2008) and, in one study, by
ethnicity (Flicker, Turner, Waldron, Ozechowski, & Brody, 2008).
Therapist experience has not been systematically manipulated in
any study, although experience did differ across studies, prompting
some thoughtful speculation (Flicker et al., 2008) about how it
might account for differing results. Therapist experience was positively associated with the alliance in conjoint alcoholism treatment for couples (Raytek, McCready, Epstein, & Hirsch, 1999),
where a qualitative analysis revealed that experienced therapists

30

FRIEDLANDER, ESCUDERO, HEATHERINGTON, AND DIAMOND

were relatively more active, more responsive to topics initiated by


clients, more flexible in following manualized treatment guidelines, and better at managing the couples negativity.

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Couples Therapy Outcomes


In general, with respect to gender, the mans alliance tends to be
more strongly associated with outcome in both group marital
therapy (e.g., Bourgeois, Sabourin, & Wright, 1990) and couples
therapy (Symonds & Horvath, 2004). Less frequently, the womans alliance is the stronger predictor of outcome (KnoblochFedders, Pinsof & Mann, 2007). Explanations for the gender
difference focus on the documented greater reluctance of men to
engage in treatment, as well as their relative power in some
couples (especially where there is abuse), and womens relatively
higher commitment and ability to work toward positive outcomes
regardless of the relative strength of their relationship with the
therapist (Symonds & Horvath, 2004, p. 453).

Family Therapy Outcomes


In outcome studies of CFT, family role emerged as the most
consistent (albeit complex) potential moderator; its effects vary
depending on the measures used and the treatment administered. A
study of family treatment for anorexia nervosa (Pereira et al.,
2006), for example, found that adolescents (but not parents)
observed alliance with the therapist predicted early weight gain,
whereas parents alliance later in therapy was associated with the
teens overall weight gain. Similarly, in a study of family treatment
for adolescent substance abuse (Shelef, Diamond, Diamond, &
Liddle, 2005), observer measures (but not self-report measures) of
adolescents alliance predicted posttreatment outcomes, whereas
parent measures did not. Moreover, adolescent alliance predicted
outcome only in cases in which the parent-therapist alliance was
moderate to strong. In a study of outpatient psychotherapy as
usual that combined individual and conjoint parent-teen sessions,
youths alliances predicted outcomes (youth symptom improvement, family functioning) as reported by all family members,
whereas parents alliance predicted fewer outcomes and only their
own (i.e., not their childrens) ratings of treatment success (Hawley & Garland, 2008). It is interesting that there is no evidence that
therapist gender, race/ethnicity, or therapist-family ethnic match
are significant factors in the strength of alliance or moderators of
the CFT alliance-outcome association.
Type of treatment may moderate the alliance-outcome relation,
given the differences in findings across studies of different treatments. In a behavioral family management treatment for schizophrenia (Smerud & Rosenfarb, 2008), only the relatives observed
alliances predicted the patients reoccurrence of symptoms. Patients alliance predicted less rejection by relatives and less care
burden, suggesting that alliances in one subsystem may have
positive effects on others. Another study (Hogue, Dauber, Faw
Stambaugh, Cecero, & Liddle, 2006) comparing cognitivebehavior therapy (CBT) and multidimensional family therapy
(MDFT) for adolescent substance abuse, found that in CBT the
adolescents alliance was not associated with outcome, whereas in
MDFT both the youths and the parents alliances were associated
with outcomes, albeit in different ways.

Only one study (Friedlander, Lambert, & Muniz de la Pena,


2008) specifically tested a mediating model. In this study, the
within-family alliance (shared sense of purpose within the family)
mediated the relationship between the parents observed sense of
safety in Session 1 and their ratings of improvement-so-far in
Session 3. In other words, parents who felt comfortable in the first
session were more likely to exhibit a strong within-family alliance
that, in turn, predicted their perceptions of improvement after the
third session.

Patient Contribution
The clinical CFT literature focuses almost exclusively on therapist behavior, with far less emphasis on client participation in
treatment. One could well argue that all client behavior contributes
to (or detracts from) the alliance. To some extent, clients collaboration in therapy depends on the therapists theoretical approach.
Couples in behavioral therapy, for example, spend less time accessing primary emotions than do couples in emotion-focused
therapy. Yet, on a different process level, alliance-related behavior
cuts across therapy approaches and formats. That is, like successful clients in individual therapy, successful family members form
a close, trusting bond with their therapists and negotiate (and
renegotiate) treatment goals and tasks. Regardless of the kinds of
in-session or out-of-session tasks, clients who have a shared sense
of purpose listen respectfully to one another, validate each others
perspective (even when they disagree), offer to compromise, and
avoid excessive cross-blaming, hostility, and sarcasm. Family
members who feel safe and comfortable in therapy are emotionally
expressive, ask each other for feedback, encourage one another to
open up and speak frankly, and share thoughts and feelings, even
painful ones, that have never been expressed at home (Friedlander
et al., 2006).

Couples Therapy
While scant, the literature offers some evidence about the personal characteristics and in-session behaviors of clients who develop strong working relationships in couples therapy. Research
suggests that whereas psychiatric symptoms are not associated
with alliance formation (Knobloch-Fedders, Pinsof, & Mann,
2004; Mamodhoussen et al., 2005), greater trust in the couple
relationship (Johnson & Talitman, 1997) and less marital distress
(Johnson & Talitman, 1997; Knobloch-Fedders et al., 2004) are
predictive of more favorable alliances. In the Knobloch-Fedders et
al. study, alliance development differed for men and women. For
men, recalling positive experiences in the family of origin was
most critical for early alliance development, whereas marital distress had a negative impact on the alliance later on. For women,
sexual dissatisfaction was negatively associated with the alliance
throughout therapy, and womens family of-origin distress contributed to a split alliance early in the process.
Regarding in-session behavior, Thomas, Werner-Wilson, and
Murphy.s (2005) results reflect the complexity of CFT alliances.
Men were less likely to agree with the therapist on the goals for
treatment when their partners made negative statements about
them, whereas women tended to feel more negative about therapy
tasks when they were challenged by their partners. Both men and
women had a stronger bond with the therapist when their partners

SPECIAL ISSUE: COUPLE AND FAMILY THERAPY ALLIANCES

self disclosed, and felt more distant from the therapist when their
partners challenged or made negative comments about them.

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Family Therapy
In community-based family therapy, parental differentiation of
self predicted stronger perceived alliances after Session 3 (Lambert & Friedlander, 2008); parents who reported being generally
less emotionally reactive tended to feel safer and more comfortable
in conjoint family therapy. Diagnosis or presenting problem may
also matter, for example, in family based therapy for anorexia
nervosa, teens with relatively more weight and eating concerns
found it particularly difficult to establish an alliance with the
therapist (Pereira et al., 2006). On the other hand, the nature of
adolescents emotional problems played no role in alliance development in a study of MDFT for drug-using adolescents (Shelef &
Diamond, 2008), where there was no variability in teens alliancerelated behavior based on pretreatment externalizing or internalizing behaviors.
Not surprisingly, alliances are stronger when family members
respond favorably to therapists alliance-building interventions. In
a comparison of two families treated by the same experienced
therapist (Friedlander, Lambert et al., 2008a), clients in the poor
outcome case were less likely than those in the good outcome case
to respond positively to the therapists alliance-related behaviors.
Another small study, although not directly assessing the alliance,
has implications for building a shared sense of purpose (Friedlander, Heatherington, Johnson, & Skowron, 1994). Family members were observed to move from disengagement with each other
to productive in-session collaboration when, with the therapists
help, they explored the underlying basis for their disengagement
and recognized motivations for breaking through it.

31

ment style may well moderate the alliance-outcome relationship in


CFT.

Therapeutic Practices
} The therapeutic alliance is a critical factor in the process and
outcome of CFT. Therapists need to be aware of what is going within
the family system while monitoring the personal bond and agreement
on goals and tasks with each individual family member. Periodically
asking clients to complete a brief measure of the alliance would
provide an opportunity for directly addressing and repairing problematic alliances.
} Shared sense of purpose within the family, a particularly important dimension of the alliance, involves establishing overarching systemic goals (e.g., It sounds like what the two of you want is a
relationship in which you feel both connected and that you can
sometimes do your own thing) rather than competing, first-order,
individual goals (i.e., I want him to stop watching sports on TV every
Saturday or I want her to give me more space). Creating a safe
space is critical, particularly early on in therapy, but doing so requires
caution. A therapist who allies too strongly with a resistant adolescent
may unwittingly damage the alliance with the parents, particularly
when the latter are expecting the teen to change but are not expecting
to be personally challenged by the therapist.
} Evaluating the alliance based on observation is a skill that can
be taught. Therapists may train themselves to validly assess their
alliances with different family members by reviewing videotaped
sessions (Carpenter, Escudero, & Rivett, 2008).
} In short, each persons alliance matters, and alliances are not
interchangeable. Each and every alliance exerts both direct and
interactive effects on the course of treatment. Thus, clinicians
should build and maintain strong alliances with each party and be
aware of the ways in which, depending on the familys dynamics,
the whole alliance is more than the sum of its parts.

Limitations of the Research


The current body of research on alliance in CFT is small but solid.
Diverse client populations and therapy approaches have been sampled, and many of the treatments studied have strong empirical
support and/or have been delivered by experienced therapists. Under
these conditions, the finding that alliances predict treatment retention
and outcome over and above specific therapy methods strengthens the
case for the unique contribution of relationship variables in CFT.
Nonetheless, there are limitations in this body of work that require
caution in interpreting the findings and applying them to practice.
These include considerable variation across studies in alliance instruments, in timing of the measurement of alliance, and sample sizes.
Much of what we know about moderators is speculative, based on
results across different studies. Further, most of the research focuses
on treatment of families of drug-abusing, externalizing adolescents;
thus is unwise to generalize from these results to families with
younger children or children with internalizing problems. The effects
of unbalanced alliances, for example, may be weaker or nonexistent in
families in which the children are less inclined to resist treatment.
Further, alliances in family treatments for adults with major mental
disorders may involve different dynamics as well. Compared with
individual therapy (see Levy et al., this issue), few studies have
examined individual characteristics (e.g., attachment style) as moderators in CFT. Given its importance for intimacy and cohesion, attach-

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Family Therapy: An International Journal, 27, 19 35.

Received September 25, 2010


Revision received October 15, 2010
Accepted October 18, 2010