Therapeutic Alliance: A Review of Sampling Strategies Reported in Marital and Family Therapy Studies
Identifieur interne : 000327 ( Istex/Corpus ); précédent : 000326; suivant : 000328Therapeutic Alliance: A Review of Sampling Strategies Reported in Marital and Family Therapy Studies
Auteurs : Barbara A. Mahaffey ; Paul F. GranelloSource :
- The Family Journal [ 1066-4807 ] ; 2007-07.
Abstract
Therapeutic alliance is considered important for successful counseling. Alliances between a therapist and couples or family members become complicated because of multiple interactions. This literature review examines sample size, participant assignment, and generalizability in 19 marital and family therapy studies on therapeutic alliance published 1989 through 2003. Eleven studies had inadequate sample sizes. Most of the assignment strategies include convenience and purposive samples conducted with YAVIS (young, adult, verbal, intelligent, stable) populations. Studies lacked diversity in participant demographics and treatment sources. None of the studies factor how therapist experience and therapeutic setting affect therapeutic alliances. These studies do support therapeutic alliance as an integral part of marital and family counseling, theory, and assessment.
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DOI: 10.1177/1066480707301314
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Alliances between a therapist and couples or family members become complicated because of multiple interactions. This literature review examines sample size, participant assignment, and generalizability in 19 marital and family therapy studies on therapeutic alliance published 1989 through 2003. Eleven studies had inadequate sample sizes. Most of the assignment strategies include convenience and purposive samples conducted with YAVIS (young, adult, verbal, intelligent, stable) populations. Studies lacked diversity in participant demographics and treatment sources. None of the studies factor how therapist experience and therapeutic setting affect therapeutic alliances. These studies do support therapeutic alliance as an integral part of marital and family counseling, theory, and assessment.</div></front></TEI><istex><corpusName>sage</corpusName><author><json:item><name>Barbara A. 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Alliances between a therapist and couples or family members become complicated because of multiple interactions. This literature review examines sample size, participant assignment, and generalizability in 19 marital and family therapy studies on therapeutic alliance published 1989 through 2003. Eleven studies had inadequate sample sizes. Most of the assignment strategies include convenience and purposive samples conducted with YAVIS (young, adult, verbal, intelligent, stable) populations. Studies lacked diversity in participant demographics and treatment sources. None of the studies factor how therapist experience and therapeutic setting affect therapeutic alliances. These studies do support therapeutic alliance as an integral part of marital and family counseling, theory, and assessment.</p></abstract><textClass><keywords scheme="keyword"><list><head>keywords</head><item><term>therapeutic alliance</term></item><item><term>family therapeutic alliance</term></item><item><term>marriage therapeutic alliance</term></item><item><term>therapeutic alliance sampling</term></item></list></keywords></textClass></profileDesc><revisionDesc><change when="2007-07">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/15DA04C91FF913F8460A8C49DF9103B6CA403B17/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus sage not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="other" dtd-version="2.3" xml:lang="EN"><front><journal-meta><journal-id journal-id-type="hwp">sptfj</journal-id><journal-id journal-id-type="publisher-id">TFJ</journal-id><journal-title>The Family Journal</journal-title><issn pub-type="ppub">1066-4807</issn><publisher> <publisher-name>Sage Publications</publisher-name> <publisher-loc>Sage CA: Los Angeles, CA</publisher-loc> </publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.1177/1066480707301314</article-id><article-id pub-id-type="publisher-id">10.1177_1066480707301314</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject></subj-group></article-categories><title-group><article-title>Therapeutic Alliance: A Review of Sampling Strategies Reported in Marital and Family Therapy Studies</article-title></title-group><contrib-group> <contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Mahaffey</surname><given-names>Barbara A.</given-names></name><aff>Ohio University-Chillicothe, The Ohio State University, <email xlink:type="simple">mahaffey@ohio.edu</email> </aff></contrib> <contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Granello</surname><given-names>Paul F.</given-names></name><aff>The Ohio State University</aff></contrib> </contrib-group><pub-date pub-type="ppub"><month>07</month><year>2007</year></pub-date><volume>15</volume><issue>3</issue><fpage>207</fpage><lpage>216</lpage><abstract> <p> <italic>Therapeutic alliance is considered important for successful counseling. Alliances between a therapist and couples or family members become complicated because of multiple interactions. This literature review examines sample size, participant assignment, and generalizability in 19 marital and family therapy studies on therapeutic alliance published 1989 through 2003. Eleven studies had inadequate sample sizes. Most of the assignment strategies include convenience and purposive samples conducted with YAVIS (young, adult, verbal, intelligent, stable) populations. Studies lacked diversity in participant demographics and treatment sources. None of the studies factor how therapist experience and therapeutic setting affect therapeutic alliances. These studies do support therapeutic alliance as an integral part of marital and family counseling, theory, and assessment.</italic> </p> </abstract><kwd-group> <kwd>therapeutic alliance</kwd> <kwd>family therapeutic alliance</kwd> <kwd>marriage therapeutic alliance</kwd> <kwd>therapeutic alliance sampling</kwd> </kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Other</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>207 ArticlesTherapeutic Alliance: A Review of Sampling Strategies Reported in Marital and Family Therapy Studies SAGE Publications, Inc.200710.1177/1066480707301314 Barbara A.Mahaffey Ohio University-Chillicothe, The Ohio State University, mahaffey@ohio.edu Paul F.Granello The Ohio State University Authors' Note: Please address correspondence to Barbara A. Mahaffey, Human Services Technology Program Director, Ohio Therapeutic alliance is considered important for successful counseling. Alliances between a therapist and couples or family members become complicated because of multiple interactions. This literature review examines sample size, participant assignment, and generalizability in 19 marital and family therapy studies on therapeutic alliance published 1989 through 2003. Eleven studies had inadequate sample sizes. Most of the assignment strategies include convenience and purposive samples conducted with YAVIS (young, adult, verbal, intelligent, stable) populations. Studies lacked diversity in participant demographics and treatment sources. None of the studies factor how therapist experience and therapeutic setting affect therapeutic alliances. These studies do support therapeutic alliance as an integral part of marital and family counseling, theory, and assessment. therapeutic alliance family therapeutic alliance marriage therapeutic alliance therapeutic alliance sampling herapeutic alliance studies of therapy sessions involving T m u l t i p l e family members and couples published recently have taken on a whole new appearance and mean- ing. Instead of the former, more popular quantitative approach used to research certain behaviors, more qualita- tive and process/outcome studies have been conducted to define and discover new therapeutic alliance theories and methodologies. Nineteen research studies of therapeutic alliance in the marriage and family therapy field dating from 1989 to 2003 were located. This literature review discusses the sampling methods used by those authors and how improvements could be made in future studies. Researchers and practitioners alike consider the alliance between a therapist and client(s) a vital part of the answer to the question, “How does therapy work?” (Wynne, 1988). The count for individual psychotherapy studies of therapeu- tic alliance totaled more than 2,000 by the year 2000 (Horvath & Bedi, 2002). This was because of the perceived importance and influence therapeutic alliance has on ther- apy outcome (Horvath & Bedi, 2002). More importantly, therapeutic alliance has been reported as a statistically and clinically significant variable for successful individual ther- apy outcome (Horvath & Bedi, 2002). The excitement has been justified but not yet verified because of the differences in research strategies and results between individual therapy and marital and family therapy. Therapeutic alliance—the client's experience of being allied with the therapist, the therapy ritual, and the goals of therapy—has warranted new attention in the research literature because of the more com- plex dynamics that occur during marital and family sessions (Wynne, 1988). The most recent and popular method to examine thera- peutic alliance has been process research, which attempts to define theories, functions, and conceptualizations (Wynne, 1988). Process studies are conducted with the notion that research results would be more concise if the phenomenon being investigated were better defined (Gurman, Kniskern, & Pinsof, 1986). Half of the studies in this literature review involved process or outcome research, and most of the stud- ies dated 1997 to the present reported using process or out- come methodology. Questions remain in the research areas of defining therapeutic alliance, measuring it as a construct, interpreting the results of the studies, and conducting further 208 research to include the special populations and situations that are unique to families or multiple client relationships. HISTORY OF THERAPEUTIC ALLIANCE RESEARCH Therapeutic alliances have been discussed as a crucial com- ponent of therapy since the beginning of individual psy- chotherapy and have been researched mostly in that venue (Horvath & Luborsky, 1993). The unique aspects of marital therapy alliances have not been well understood (Rait, 2000). According to Faloon (1991), the need for therapist training to improve therapeutic alliance skill building in the behavior fam- ily therapy approach became apparent in 1985. More recently, therapeutic alliance became a goal for supervisors to facilitate therapist training (Neufeldt, 2004). Unlike its noted effects on individual psychotherapy, therapeutic alliance has only recently been deemed important in marital therapy outcome research (Coupland & Serovich, 1999; Gurman et al., 1986). THERAPEUTIC ALLIANCE THEORIES DEFINED The theoretical conceptualization of therapeutic alliance has been confusing (J. M. Serovich, personal communication, March 2, 2004). Originally, therapeutic alliance was empiri- cally investigated as an integral and common occurrence in most therapy sessions and was examined in an effort to deter- mine the efficacy of theoretical approaches (Horvath & Bedi, 2002). Also, theoretical hypotheses have been confusing because the term itself has evolved and changed several times: alliance, therapeutic relationship, working alliance, therapeu- tic bond, and helping alliance (Horvath & Luborsky, 1993; Martin, Garske, & Davis, 2000). Therapeutic alliance has been thought of as a single con- struct (Martin et al., 2000) or multidimensional (Bordin, 1979; Luborsky, 1994; Pinsof, 1994; Reif, 1997; Rugel, 1997; Tolan, Hanish, McKay, & Dickey, 2002; Werner-Wilson, Michaels, Thomas, & Thiesen, 2003) or existing in a constant state of flux (Patalano, 1997). Therapeutic alliance was defined by Kaplan and Sadock (1998) and originally by Bordin (1979) as both the therapist and the client(s) commitment to exploring problems, establishing a mutual trust, and cooperating to achieve a realis- tic goal of curing or ameliorating the symptoms. Pinsof (1988) defined therapeutic alliance as an interlocking part of an inter- personal relationship between a therapist and the patient sys- tems. Thus, it is the therapist's responsibility to frame therapy and help the couple understand and identify with the treatment process (Patalano, 1997). Other theorists explored different components of the therapeutic alliance in terms of the therapist/client(s) rela- tionship. Trust, rapport, and resistance are terms associated with therapeutic alliance building that occurs between ther- apist and client(s). Client trust has been thought to strengthen the therapeutic alliance during the therapeutic process (Patalano, 1997). How therapeutic alliance building has been used has varied. For example, a structural therapist may have chosen to join with one spouse to act as a cother- apist in the session (Rait, 2000), whereas a communication therapist may have advocated that the therapist should treat clients equally with respect (Satir, 1967). Pinsof and Catherall (1986), family systems theorists, described thera- peutic alliance in family therapy as beginning with each family member, the individual, and evolving to a higher order level with the whole family system becoming allied with the therapist. According to Pinsof and Catherall, the therapist role would be to develop an alliance with each of the multiperson subsystems (i.e., parents, children) that impacted others in the family, referred to as the subsystem alliance, in a circular or reciprocal fashion. Therapeutic alliance has been described by Rugel (1997) in marital therapy as having multiple factors. Rugel believed that for marital therapy to be effective, a therapeutic alliance between the couple and the therapist must be formed. Also, the therapist is to come to an understanding about the nature of the couple's marital problems. To form a bond with the cou- ple, the therapist would show acceptance, involvement, empathy, empathic probing, and competence with each spouse's marital reality (Rugel, 1997). In his book based on his clinical experience, Rugel emphasized winning the approval of a husband during the marital session by being in tune with the husband's distaste of therapy and conveying an understanding of his discomfort. Focusing on the husband, overcoming resis- tance, and obtaining the husband's cooperation during a ses- sion are crucial steps in building the therapeutic alliance (Rugel, 1997). Different factors that affect the wife's thera- peutic alliance with the therapist have yet to be researched. DEFINING THERAPEUTIC ALLIANCE CREATED DIFFICULTIES FOR RESEARCHERS The study of therapeutic alliance in marital and family ther- apy has been deemed complicated because of the nature of interpersonal communication among the therapist or therapists and the clients, also referred to in the literature as the session dynamics. Some researchers realized the therapist is expected to develop an alliance with each individual as well as the cou- ple subsystem, within the context of the relationship triangles (e.g., Hight, 1997; Rait, 2000). This creates a situation where the therapeutic relationship may not be as intense as in an indi- vidual session, for the therapist may not respond to all the communication triangles in the session. Possible miscommu- nication may occur as well. Some comments made by the ther- apist(s) may be interpreted by clients as indirect messages to other family members (Heatherington & Friedlander, 1990). Multifaceted variables have impacted the quality of the marital and family therapy therapeutic alliance research results. Especially interesting are the vast differences in the areas of sample size, assignment, and generalizability of the findings. Client and therapist intrapersonal and interpersonal factors (Horvath & Luborsky, 1993), phases or stages of the therapy (Haslam-Hopwood, 2003; Horvath & Luborsky, 209 1993), and therapy levels (Rait, 2000) of therapeutic alliance have been empirically researched. Therapeutic alliance has been reported to have multiple roles dependent on many the- oretical approaches (Gurman & Jacobson, 1995). Still other research topics sought to examine therapist techniques such as genogram use with clients (e.g., Coupland & Serovich, 1999; Horvath & Luborsky, 1993). Much work will be needed to better understand therapeutic alliance. Areas mentioned in the literature for further investi- gation were therapist experience (Raytek, McGrady, Epstein, & Hirsch, 1999) and gender (Heatherington & Friedlander, 1990; Werner-Wilson et al., 2003). Difficulties with attaining therapeutic alliance have been the focus of few empirical and anecdotal reports. Dysfunctions in therapeutic alliances are known as misalliances or therapeutic ruptures (Safron & Muran, 1998). In his tome, Rugel (1997) posited that some marital therapists have not been as successful in gaining an alliance because of the therapist not accepting the husband's prior socialization attributes and not focusing on specific prob- lems. Patalano (1977) noted the therapeutic alliance can be weakened by the therapist's failure to empathize with the client and by the unmotivated partner consciously or unconsciously sabotaging the alliance. The sessions being noisier and more conflicted may be have deterred alliances in marital therapy when compared to individual therapy (Rait, 2000). Clearly, misalliances involving many of the special populations and diversities in marital and family therapy are a research gap. THE IMPORTANCE OF EXAMINING SAMPLE SIZE The sampling strategies included in this review were sam- ple size, sample assignment, and generalizability of the results. Sampling strategies are important in most, but not all, research for aiding future researchers in the decision making about who was researched in what situation, in aspects of selection and observation of participants, and for proper analysis of the statistical measures to be used in the study (Ary, Jacobs, & Razavieh, 2002). The planning and selection of sample size by researchers affects the power or probability of results, and is paramount in establishing statistical significance (Cohen, 1992). Marital and family therapy studies examined for thera- peutic alliance characteristics tended to have varied sample sizes, depending on the participants' availability and the research's purpose, proximity, available funding, and timing. FACTORS THAT AFFECT THE GENERALIZATION OF RESEARCH FINDINGS Assignment strategies, the practice where researchers choose the number or the diversity of participants counted in control or treatment groups (Glass & Hopkins, 1984), have been another crucial way researchers analyze the validity of the inferences made from the sample to a population parame- ter. A sample's being representative of the general population has been called generalizability (Best & Kahn, 1993). Having a large and diverse sample promotes the reliability and valid- ity of the research results, but only when the sample reflects the population make-up in the many variables such as gender, socio-economic status, age, and ethnicity (Best & Kahn, 1993). Mistakes in the sampling methodology can lead to biased research results and variable definition problems (Gravetter & Wallnau, 2004). When the work has been deemed valid, qualitative studies about therapeutic research are more respected and are thought to be more valuable (J. M. Serovich, personal communication, March 2, 2004). MEASURING THERAPEUTIC ALLIANCE Most of this review's qualitative studies involved client self-reports or therapist checklists or reports as the data source and have slight time of assessment phase differences (Horvath & Bedi, 2002). Some authors of therapeutic alliance studies devised assessment tools that have positively linked alliance measures to therapy outcome across different therapeutic dimensions with a wide variety of research groups (Horvath & Bedi, 2002; Pinsof, 1988). In a little-used methodology for marital and family studies, Horvath and Bedi noted that another strategy caveat to therapeutic alliance assessment has been the use of trained observers who code or rate the thera- peutic relationship from an inferential perspective. There are at least 24 therapeutic alliance scales, with most of the recent ones created to adapt to the many caveats of treat- ment outcomes or populations (Horvath & Bedi, 2002). Martin et al. (2000) stated that the original scales attempted to address individual therapeutic alliance based on various theories and were the impetuses for group, couple, and family scales. Pinsof and Catherall (1986) devised a set of therapeutic alliance scales specifically for couples and family therapy. The use of the many therapeutic alliance scales has been troubling for researchers. One problem was that some questionnaires used were designed for a particular group of people or for a related concept, such as empathy (Horvath & Bedi, 2002), which may affect how the results could be construed. Mixing the ways that alliance was measured proved trou- blesome for some of the researchers. Different measures were calculated to include varied weights on therapeutic alliance core elements; therefore, they were to be considered separate entities (Horvath & Bedi, 2002). Study results of assessments conducted by trained observers coding behavioral interactions were not homogenous (Horvath & Bedi, 2002) when com- pared with the self-report checklist scores or to the character- istics of clients who fill out personality or symptom checklist inventories prior to intake. Further refinement in research strategies and conceptualizations are warranted for the many therapeutic alliance scales to capture information about special populations, especially children, teens, elderly, and the culturally diverse, and the differing therapeutic interventions used with marital and family therapy clien- tele (e.g., Hampson, Prince, & Beavers, 1999; Hight, 1997; 210 High Reif 211 othe ling; 2 ma ; 2 A sian; 212 al and of Thera apeutic 213 Holtzworth-Munroe, Jacobson, DeKlyen, & Whisman, 1989; Johnson, Wright, & Ketring, 2002; Tolan et al., 2002). METHOD A total of 19 relevant studies (published in 18 articles and dissertations) published between 1989 and 2003 were located for this literature review. Because of time constraints, articles before 1988 and after 2003 were delimited. Differing descrip- tors of alliance, therapeutic alliance, working alliance, thera- peutic relationship, and therapeutic alliance were searched in a review of Ohio Link, Psych Info, Dissertation Abstracts, medical journal articles, and research databases. A hand search of journals was conducted at a large midwestern university library. The last 10 years of The Marital and Family Therapy Journal, The Journal of Family Psychology, The Journal of Family Therapy, The Family Journal, Family Process, and The American Journal of Family Therapy were searched. The hand search of the marital and family journals resulted in only a few located articles (refer to Table 1), so the search was expanded to include other journals and sources. Most of the 4,000 plus hits on the library computer search revealed a preponderance of individual psychotherapy therapeutic alliance studies. References from located arti- cles were also scanned for sources. There were three book sources (Garfield & Bergin, 1986; Norcross, 2002; Wynne, 1988) that included brief subheadings reviewing marital and family therapy therapeutic alliances, and three books (Horvath & Greenberg, 1994; Levy, 2000; Safron & Muran, 1998) that focused on individual therapeutic alliances but contained background information used in writing this article. Delimited from this review were psychotherapy therapeutic alliance stud- ies of individual clients, articles reviewing clinical illustra- tions, single case examples, studies prior to 1989 (because of feasibility), studies published in multiple articles, and hypo- thetical case reviews. Reviews of therapeutic alliance ruptures, dissertations published before 1996, and one unavailable dis- sertation (Van Roosmalen, 2001) were also delimited. REVIEW OF SAMPLE SIZE, ASSIGNMENT, AND GENERALIZABILITY The purpose of this therapeutic alliance literature review was to investigate sample size, assignment, and generaliz- ability methodologies. To accomplish this, the different sample sizes and strategies for marital and family therapy therapeutic alliance studies were examined for variations and similarities (see Table 1). This listing showed limited diversity in characteristics and rationale. The studies explored multiple alliance characteristics: different therapist attrib- utes (Davenport & Ratliff, 2001; Raytek et al., 1999; Reif, 1997; Werner-Wilson et al., 2003), client risk factors and view points (Glueckauf, Liss, McQuillen, Webb, Dairaghi, & Carter, 2002; Hampson et al., 1999; Heatherington & Friedlander, 1990; Tolan et al., 2002), and client and therapist behaviors (Holtzworth-Munroe et al., 1989). Also examined were special population nuances: group marital therapy suc- cesses (e.g., Bourgeois, Saborin, & Wright, 1990), adoles- cents in distress (e.g., Diamond, Diamond, & Liddle, 2000; Johnson et al., 2002; Robbins, Turner, Alexander, & Perez, 2003), grounded theory to explain successful and unsuc- cessful treatment (e.g., Alexander, 1997), treatment out- comes (e.g., Hight, 1997), family alliances (e.g., Terry, 2002), and specific approaches (e.g., Coupland & Serovich, 1999; Miller, 2003). RESULTS The marital and family therapy field creates, by nature, dif- ficulties in obtaining a representative sample size. Couples and families may have a variety of members and presenting prob- lems. This variety created difficulty in comparisons of results as well as for comparing the results to the characteristics of the general population. For example, most of the researchers used convenience or purposive sampling strategies because they studied available participants, increasing the studies' feasibil- ity and economical selection. Research methodology may pre- sent complex data analysis issues (Best & Kahn, 1993). Some of the researchers in the reviewed studies believed therapeutic alliance had an impact on treatment outcome (Miller, 2003) and tried to use a large sample size to overcome the barrier to generalizability for this reason (e.g., Bourgeois et al., 1990; Hampson et al., 1999; Raytek et al., 1999; Tolan et al., 2002). Cohen's (1992) assertion has been that the power of a treat- ment effect is an important indicator of the probability that the research study results are representative of the general popula- tion. Larger sample sizes in these previous research studies would have ensured that the treatment effect would have been more representative of the population (Gravetter & Wallnau, 2004). Many authors noted problems with their studies' sam- ple size (e.g., Alexander, 1997; Coupland & Serovich, 1999; Davenport & Ratliff, 2001; Glueckauf et al., 2002; Hight, 1997; Holtzworth-Munroe et al., 1989; Johnson et al., 2002; Miller, 2003; Robbins et al., 2003; Terry, 2002; Tolan et al., 2002). Only one pair of authors mentioned power in calcu- lating their statistical analysis of sample size (Coupland & Serovich, 1999). The studies were found to have participant assignment strategy problems. The participant assignment strategies (see Table 1) differed from the conventional random assign- ments that are commonly used in scientific study (Best & Kahn, 1993). Only one study had random assignment of its participants as its assignment strategy (e.g., Raytek et al., 1999). Another research method to improve the external validity would have been to use a control group. Terry (2002) posited the need for more control groups to be used to give more weight to the study results. Research has explored only a few of the marital and fam- ily therapy diverse factors or clinician or client attributes. Researchers have yet to decipher several issues relating to 214 generalizing results. For example, client ages can range from young children to older adults. As in other social sci- ence research areas, most of the researchers focused on the YAVIS (young, adult, verbal, intelligent, and stable) popula- tions (Miller, 2003). Nine studies did include children in their samples (e.g., Davenport & Ratliff, 2001; Diamond et al., 2000; Gleuckauf et al., 2002; Johnson et al., 2002; Heatherington & Friedlander, 1990; Robbins et al., 2003; Terry, 2002; and the two studies discussed in Tolan et al., 2002). Two researchers noticed other research needs. Bourgeois et al. (1990) called for researchers to aid clinical practitioners with information on how to bond with couples in crisis. Alexander (1997) noted the need for longitudinal studies and more heterogeneous demographical information to be included to broaden the scope of generalizability. Researchers examining diversity in many client populations involved in marital, couple, and family therapeutic alliance studies have only begun to explore the many and varied con- textual and/or cultural components (Wynne, 1988). Other methodological concerns, when considering the nature of therapeutic alliance, were the wording, timing, and interval spacing of the assessment tools during the course of the studies. For example, Holtzworth-Munroe et al. (1989) expressed a need for more sophisticated measures to examine client attributes and therapist actions. There are no assessment tools that have both members of a couple or an entire family reporting on their perceptions of their therapeutic alliance with a therapist or therapists. Also missing in the reporting was a crosstabulation of the multiple client factors. Suggesting a change in research methods, Hight (1997) asserted that mea- suring therapeutic alliances frequently with detailed history and diversity in rating strategies may help researchers better understand how therapeutic alliance may change with the same clients over time. Comparing any of the instrument's pretests and posttests client rating scores may have provided a deeper understanding of the therapeutic alliance between ther- apist and client(s). CLINICAL IMPLICATIONS Therapists will face continual changes and challenges in gaining therapeutic alliances, with the population becoming even more diverse in characteristics and with the evolving facets of family and marital issues. Therapeutic alliance has been heralded as one of the most important factors in suc- cessful individual counseling and is regarded as an important variable in many types of marital and family therapy. This literature review sought to examine three aspects of sam- pling strategies that were used. The most pressing problems noted in this review were due in part to some aspect of the sampling strategies methodology. In no way should these problems cast doubt on the need for therapeutic alliance building. Clinicians need to be encouraged to use the assess- ment scales, to examine their use of techniques, and to be more aware of the multiplicity and complications involved in building therapeutic alliances. Then, clinicians can report their findings. IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE One important realization for therapists and researchers is that couples and families often begin treatment with a multi- plicity of presenting problems and differing degrees of inter- est, motivation, goals, and beliefs about how to change (Patalano, 1997; Rait, 2000). These factors create a problem for researchers, who are grappling with various research methods in an effort to account for assignment strategies and find generalizabilities in samples. Confounding variables may have plagued and confused study results, again affecting how the results can be seen as representative of the general popu- lation, based on theory use (Luborsky, 1994) and the types of samples studied (Best & Kahn, 1993; see also Davenport & Ratliff, 2001; Glueckauf et al., 2002; Johnson et al., 2002; Robbins et al., 2003). Another possible generalizability prob- lem was that therapeutic alliance researchers have studied mostly doctoral, graduate, or outpatient therapist treatment sources. No study specifically mentioned the differences of therapist experience or how therapeutic setting affected ther- apeutic alliances with multiple family members or couples or with differing cultural groups. Researchers have examined many therapist variables in relation to individual counseling sessions but none of the reviewed marital or family therapy selected studies addressed therapist variables. This literature review uncovered other concerns about sam- pling strategies. There has not been a dialogue about what hap- pens when therapists do not believe in or ignore therapeutic alliances or fail to gain them. Misalliances are difficult to research. Study participants who drop out of treatment are usu- ally not queried or may be reported as lost to the study. This gap has been understandable because clients who no longer show up for sessions as well as the therapists who treat them are hesitant to answer questions. For example, the possibility still exists that one of the spouses or family members may be coming to sessions involuntarily (Rait, 2000), a unique yet unexplored area in therapeutic alliance research. Especially ignored in the research was positing one concise theory of therapeutic alliance. Also missing was a theory that explained how the multiple variables could have hindered the formation of therapeutic alliances. Information about special populations was the biggest gap in the research. There was a lack of gender issues exploration in marital and family issues. Bourgeois et al. (1990) and Rugel (1997) suggested that ther- apists become more aware of the importance of men feeling understood and the tasks and objectives to be agreed upon and stated in the early phases of treatment. Furthermore, therapists could benefit from learning more about the many differences in family rules, developmental stages, and cultural nuances. The relationship dynamics in marriage and family therapy are important aspects and difficult to research. Factors of 215 therapeutic alliance and their measurement tools merit con- tinued development of theory, research, and practice explo- rations. First and foremost, the complex multiplicity of the interactions between marital and family therapists and their client couples or family members should be recognized. Equally important for researchers and practitioners alike, there are differing theories, methodologies, assessment tools, perspectives, and strategies yet to be clarified and explored (Pinsof, 1988; Wynne, 1988). For example, no studies have been conducted with families who have special needs children or sexual identity development issues. Reimers (2001) suggested that attention and new research projects be initiated to study therapeutic approaches that focus on outcomes and therapeutic relationships. Heatherington and Friedlander (1990) hinted that future studies could examine the differences in theoretical concepts, such as comparing a therapeutic approach that encourages therapist neutrality with one that supports the therapist forming shifting coalitions within the family. Therapeutic alliance studies in marital and family therapy, with all their many characteristics, theories, variables, and relationship factors, warrant a renewed interest in approaches, technique use, methodological refinements, research, and therapist attention in the session. Family and marital therapy has a myriad of possible client attributes that are variables needing examination (Holtzworth- Munroe et al., 1989; Robbins et al., 2003; Werner-Wilson et al., 2003). New theoretical advances, different technique use (Coupland & Serovich, 1999) and therapist training (Johnson et al., 2002) to promote alliances warrant future research. Adequate sample sizes, random or proper sample assignment strategies, inclusion of special populations, and use of control groups would promote the formation of ther- apeutic alliances. 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Mahaffey, MEd, is an assistant professor and program director of the Human Services Technology program at Ohio University. She is a licensed professional clinical counselor with supervising credentials. Barbara has served her community for 27 years, and for the past 10 years Barbara has specialized in marriage and family counseling in private practice. She is also a doctoral candidate at The Ohio State University. Her current research projects include adoption counseling outcome and the effectiveness of partial hospitalization programming. Paul F. Granello, PhD, is an associate professor of counselor edu- cation at The Ohio State University. He is a licensed professional clinical counselor with supervising credentials. 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Alliances between a therapist and couples or family members become complicated because of multiple interactions. This literature review examines sample size, participant assignment, and generalizability in 19 marital and family therapy studies on therapeutic alliance published 1989 through 2003. Eleven studies had inadequate sample sizes. Most of the assignment strategies include convenience and purposive samples conducted with YAVIS (young, adult, verbal, intelligent, stable) populations. Studies lacked diversity in participant demographics and treatment sources. None of the studies factor how therapist experience and therapeutic setting affect therapeutic alliances. These studies do support therapeutic alliance as an integral part of marital and family counseling, theory, and assessment.</abstract><subject><genre>keywords</genre><topic>therapeutic alliance</topic><topic>family therapeutic alliance</topic><topic>marriage therapeutic alliance</topic><topic>therapeutic alliance sampling</topic></subject><relatedItem type="host"><titleInfo><title>The Family Journal</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1066-4807</identifier><identifier type="eISSN">1552-3950</identifier><identifier type="PublisherID">TFJ</identifier><identifier type="PublisherID-hwp">sptfj</identifier><part><date>2007</date><detail type="volume"><caption>vol.</caption><number>15</number></detail><detail type="issue"><caption>no.</caption><number>3</number></detail><extent unit="pages"><start>207</start><end>216</end></extent></part></relatedItem><identifier type="istex">15DA04C91FF913F8460A8C49DF9103B6CA403B17</identifier><identifier type="DOI">10.1177/1066480707301314</identifier><identifier type="ArticleID">10.1177_1066480707301314</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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