Psychotherapy ALLIANCE-BUILDING INTERVENTIONS WITH ADOLESCENTS IN FAMILY THERAPY… ·...

Psychotherapy Volume 36/Winter 1999/Number 4

ALLIANCE-BUILDING INTERVENTIONS WITHADOLESCENTS IN FAMILY THERAPY: A PROCESS STUDY

GARY M. DIAMONDBen-Gurion University of the Negev

AARON HOGUEFordham University

This exploratory, process-research studyidentified, articulated, and measuredtherapist behaviors associated withimproving initially poor therapist-adolescent alliances in multidimensionalfamily therapy (MDFT). A list ofpreliminary alliance-buildinginterventions was generated from MDFTtheory and adolescent developmentresearch. This list was then refinedthrough the observation of videotapedMDFT sessions. A sample of fiveimproved and five unimproved alliancecases was then drawn from a largertreatment study. Participants wereprimarily African American, male,adolescent substance abusers and theirfamilies. Coders rated the first threesessions of each case (30 sessions) to

This article is based upon the dissertation research of thefirst author. This research was supported by dissertationawards from the American Association for Marriage and Fam-ily Therapy and from the Division of Family Psychologyof the American Psychological Association, and by researchgrants from Temple University and from the National Instituteon Drug Abuse (P50 DA07697 and IROIDA 09424-01, H.Liddle, Principal Investigator). The authors wish to thank JodiLeckrone for her help in developing the ABBS and codertraining. This manuscript was enhanced by the comments ofStephen Shirk and Nachshon Meiran.

Correspondence regarding this article should be addressedto Gary M. Diamond, Department of Behavioral Sciences,Ben-Gurion University of the Negev, Beer-Sheva, 84105, Is-rael. E-mail: [email protected]

HOWARD A. LIDDLEUniversity of Miami School of Medicine

GAYLE A. DAKOFUniversity of Miami School of Medicine

determine the extent to which eachalliance-building intervention wasemployed. By session three, therapistswere attending to the adolescent'sexperience, formulating personallymeaningful goals, and presenting as theadolescent's ally more extensively in theimproved alliance cases than in theunimproved alliance cases. Using thesedata, proposed stages of alliancebuilding with adolescents are discussed.

Establishing a strong therapist-client alliancewithin the first few hours of therapy is criticalto the psychotherapeutic process (Horvath, 1994;Horvath & Symonds, 1991). When clients andtherapists agree on the goals and tasks of therapyand like, trust, and respect one another early intreatment, outcome, retention, and client satisfac-tion are enhanced. These findings are consistentacross various individual and couples psychother-apies with adults (Bourgeois, Sabourin, &Wright, 1990; Gaston, 1990; Holtzworth-Munroe, Jacobson, DeKlyen, & Whisman, 1989;Horvath & Symonds, 1991). Some evidence sug-gests that alliance formation is also associatedwith client satisfaction and treatment progresswith adolescents (Eltz, Shirk, & Sarlin, 1995;Shapiro, Welker, & Jacobson, 1997; Taylor, Ad-elman, & Kaser-Boyd, 1986).

While studies of the therapeutic alliance in in-dividual therapy have increased dramatically overthe past decade, the role of the therapeutic alli-ance in family therapy has been generally under-valued (Coady, 1992) and insufficiently re-searched (Friedlander, Wildman, Heatherington,& Skowron, 1994; Pinsof, 1994). This may be

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due to the systemic (i.e., focus on whole familyprocesses) underpinnings of most family therapymodels and their emphasis on behavioral interac-tions between family members rather than on in-teractions between individual family membersand the therapist. In an attempt to define the con-struct of the alliance in family therapy, Pinsof(1994) presented an integrative model that ac-counts for the therapist's working relationshipwith each family member, with each subsystem,and with the family as a whole. This theoreticalmodel captures the complexity of the therapeuticrelationship in family therapy, as therapists at-tempt to form and maintain multiple, simulta-neous, and sometimes competing alliances (Lid-dle, 1995). Not surprisingly, research has shownthat alliance "splits" frequently occur, in whichthe therapist has a strong alliance with one familymember or subsystem and a weaker alliance withothers (Heatherington & Friedlander, 1990; Pin-sof & Catherall, 1986).

The nature and relative importance of the fam-ily therapist's relationship with each family mem-ber may vary according to several factors, in-cluding the family's interactional style, thepresenting problem, the stage of therapy, and thedevelopmental level of each family member.Therapists treating young children, for example,may invest primarily in their relationship withparents, who frequently have the most leverageand, arguably, the most potential to effectchange. On the other hand, therapists treatingadolescents must recognize teenagers' power tofacilitate or challenge the therapeutic process.From a family therapy perspective, a respectful,supportive, yet demanding therapist-adolescentrelationship provides an important context inwhich teenagers can identify and clarify the goals,thoughts, and feelings that they find importantand will later introduce in conversations with theirparents. Furthermore, a strong therapist-adolescent alliance supports adolescents duringemotional and often difficult in-session enact-ments. This support allows teenagers to discloseto parents what are often vulnerable and previ-ously unspoken thoughts and feelings. Whenmodulated, such disclosures frequently lead togreater understanding and expressions of warmthon the part of parents. This results in more posi-tive, less hostile parent-adolescent interactionsand reinforces adolescents' participation in thetreatment process (Diamond & Liddle, 1996; Lid-dle & Diamond, 1991).

Forming workable, good alliances with adoles-cents, however, is challenging. Between 50% and75% of children and adolescents referred for ther-apy either do not initiate treatment or terminateprematurely (Kazdin, 1990; Viale-Val, Rosen-thal, Curtis, & Marohn, 1984). The attrition ratesfor African American and economically disadvan-taged adolescents, populations who are overrepre-sented in clinical samples, may be even higher(Kazdin, Stolar, & Marciano, 1995). Further-more, many adolescents arrive for therapy unwill-ingly. Research indicates that adolescents withbehavior problems approach therapy reluctantly(Taylor, Adelman, & Kaser-Boyd, 1985) andpresent with more negativity than other familymembers (Robbins, Alexander, Newell, &Turner, 1996).

Given the key role of alliance in treatment out-come and the importance of a strong therapist-adolescent alliance to the process of family ther-apy (Liddle, 1995), transforming adolescents'initial reluctance and negativity into collaborationis one of the first and one of the most criticaltherapeutic tasks. Improving what often beginsas a weak therapist-adolescent alliance requiresclinically based, empirically supported strategies.The need to specify and test interventions associ-ated with critical treatment processes, such asalliance formation, has been emphasized in thetreatment development literature (Kazdin, 1994).

Unfortunately, there has been a paucity of re-search on essential treatment processes in familytherapy (Diamond & Diamond, in press; Kazdin,1994) and no published studies on forming alli-ances with adolescents in family therapy. Therehave been, however, a number of studies examin-ing the process of alliance formation in individualtherapy with adults. In an exemplary study bySafran and colleagues, the authors employed atask-analytic approach to map out therapist-clientsequences associated with repairing alliance rup-tures (Safran, Muran, & Samstag, 1994). Otherstudies have compared therapist behavior ininitially poor alliances that improved over timewith initially poor alliances that did not improve(Foreman & Marmar, 1985; Gaston, Marmar, &Ring, 1988; Kivlighan & Schmitz, 1992). Resultsof these between-group comparisons suggest thata number of standard psychodynamic techniques,including directly addressing clients' negativefeelings toward the therapist, were associatedwith improved alliances (Foreman & Marmar,1985; Kivlighan & Schmitz, 1992).

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Alliance-Building Interventions

The generalizability of these results to adoles-cents may be limited. A study by Linscott, DiGiu-seppe, and Jilton (1993) found that a number oftraditional psychodynamic interventions, andother common therapy techniques, were nega-tively correlated with the strength of the therapist-adolescent alliance. For example, the more fre-quently therapists reported using free associationin the here and now, transference interpretations,and silence, the poorer the alliance. Such results,divergent from those found in research withadults, echo Shirk and Saiz's (1992) warningagainst the simple downward extension of adult-oriented therapeutic procedures with youth. Theformulation and testing of alliance-building tech-niques for teenagers must consider the uniqueaspects of this developmental stage or risk beingineffective (DiGiuseppe, Linscott, & Jilton,1996; Holmbeck & Updegrove, 1995; Liddle,Rowe, Dakof, & Lyke, 1998).

One developmental process with implicationsfor alliance formation is adolescent autonomy de-velopment. During adolescence, teenagers andparents engage in the mutual and reciprocal pro-cess of redefining their relationships so that closeties are maintained while the teenager's individu-ality emerges (Steinberg, 1990). Healthy auton-omy development is facilitated when parentsgrant adolescents increasing psychological free-dom, remain emotionally available, and expectand enforce responsible behavior (Allen, Hauser,Bell, & O'Connor, 1994; Baumrind, 1991;Steinberg, 1990; Youniss & Smollar, 1985). Asimilar approach by therapists may facilitate theformation of the therapeutic alliance. Church(1994) found that when therapists present them-selves as partners, encourage adolescents to workout their own solutions, show a willingness todiscuss adolescents' negative feelings about thetherapy and the therapeutic relationship, take re-sponsibility for confidentiality, and provide rea-sonable structure for the session, adolescents re-spond by talking more about the therapy or thetherapeutic relationship and by more frequentlyasking the therapist for advice. Adolescent clientswho experience the enhancement of personal au-tonomy in therapy show the highest degree ofsatisfaction with treatment at termination (Tayloret al., 1986).

Cognitive developmental level may also play arole in alliance formation. In their sociocognitivemodel of alliance formation in child therapy,Shirk and Saiz (1992) asserted that childrens' re-

lationships with their therapists and the extentto which they participate in treatment may bemediated by their beliefs about the need forchange, the causal locus of problems, and thecontingency of problem solution. Children maybecome allies in treatment only to the degree thatthey believe change is necessary or desirable, un-derstand the role they play in the problem's for-mation or maintenance, and believe that they caneffect positive change. Indirect empirical evi-dence for this formulation exists. Weisz (1986)found that problem resolution during psychother-apy was predicted by adolescents' beliefs abouttheir own competency and about whether peoplelike themselves could resolve problems. Al-though Weisz did not measure adolescents' be-haviors per se, he suggested that it was adoles-cents' investment of energy in the therapeuticprocess, which was commensurate with their be-liefs about control, that predicted outcome. Pro-moting adolescents' sense of competence and self-efficacy may enhance the strength of the therapist-adolescent alliance.

This study examined therapist behaviors asso-ciated with improving initially poor therapist-adolescent alliances in multidimensional familytherapy (MDFT; Liddle, 1991). MDFT is basedon structural family therapy (Minuchin, 1974)and on an empirical understanding of normativeadolescent development (Liddle, in press).MDFT has been identified as one of few integ-rative family therapy models with empirical evi-dence for its efficacy (Lebow & Gurman, 1995;Nichols & Schwartz, 1998; Stanton & Shadish,1997; Waldron, 1997; Winters, Latimer, &Stinchfield, 1998). The MDFT program of re-search is summarized elsewhere (Liddle &Hogue, in press).

Because this study represents a step into empir-ically unchartered territory, our research was ex-ploratory rather than confirmatory in nature. Wefocused on what we consider a critical-changeepisode (Greenberg, 1986): initially poor therapist-adolescent alliances that improved by the third ses-sion of therapy. The first phase of this study wasdiscovery oriented. We took an intensive, in-depthlook at a small number of cases in order to observe,articulate, and measure therapist interventions asso-ciated with improved alliances in actual family ther-apy sessions (Greenberg, 1991; Mahrer, 1988).Such observations lead to the formulation ofhypotheses and are an essential first step in thetreatment development process (Hill, 1990). The

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second phase of this study involved exploratory,empirical analyses of patterns of therapist behav-iors. Specifically, we examined whether patterns oftherapist behaviors distinguished between improvedand unimproved alliance cases.

Methods

Generating a Preliminary List of Alliance-Building Behaviors

First, a preliminary list of proposed therapistalliance-building interventions was constructed.This list, based on MDFT theory, adolescent de-velopment research, and clinical experience withsubstance-abusing and delinquent adolescents, in-cluded three interventions: developing a collabo-rative set, goal formation, and generating hope(see Diamond & Liddle, 1998; Liddle & Dia-mond, 1991). This preliminary list was designedto guide and organize our observations of thera-pist behaviors as they occurred in actual caseswith improved alliances.

Discovery-Oriented Observation of Instances ofImproved Alliances

The next step involved selecting instances ofimproved alliances for investigation. MDFT ther-apists participating in a large, controlled clinicaltrial were each asked to nominate one or two casesmost representative of initially poor alliances thatimproved by the third session of treatment. Fromthese nominations, one case from each therapistwas randomly chosen (5 cases in total). Onlycases that did not meet inclusion criteria for thelater exploratory, empirical phase of this study(e.g., lacked a full set of videotapes, adolescentdid not attend three of the first five sessions, etc.)were sampled. Two tapes from among the firstthree sessions of each case (ten tapes in all) werethen randomly chosen.

Once tapes of putatively improved allianceshad been selected, we began the process of refin-ing our description of therapist alliance-buildinginterventions to reflect how these behaviors ap-peared in actual family-therapy sessions. The firstauthor and a research assistant observed the tenimproved-alliance sessions. Using the prelimi-nary list of alliance-building interventions as ourguide, we sought to discover variations of theseinterventions, new classes of interventions, andexemplars of these interventions. A descriptionof how we revised the formulating-goals itemhelps to illustrate this overall process. We ob-

served, for example, that when helping adoles-cents formulate goals for therapy, therapists var-ied in the degree to which they verified whetherthe adolescent endorsed the proposed treatmentgoals. In some cases, therapists were careful to"check-in" with the adolescent (i.e., Does thissound like something you would like to workon?). In other instances, therapists simply as-sumed that the adolescent was invested in theformulated goal when, in fact, the adolescent'sbehavior suggested that he or she was disengaged.Consequently, the formulating-goals item waschanged to include only those instances in whichthe therapist overtly assessed the adolescent's ac-ceptance of the therapy goals. The product of thisprocess was a comprehensive, observation-basedarticulation of therapist alliance-building tech-niques in early sessions of MDFT (see Table 1).

Exploratory Empirical Analyses

After describing proposed alliance building inter-ventions, we were interested in whether (a) others(naive raters) could reliably identify and measurethese behavior and (b) these behaviors were of em-pirical importance (i.e., associated with improvedalliances). Two new groups of cases that were notincluded in the discovery-oriented phase of the proj-ect, a group of 5 cases with improved alliances anda group of 5 cases with unimproved alliances, wereselected from the same, larger clinical trial (seeProcedures). The two groups were equivalent onthree variables: initial alliance scores, adolescents'pretherapy interpersonal functioning, and theamount of time therapist and adolescent spent to-gether over the first three sessions of treatment.Prior research has shown that client's pretherapyinterpersonal functioning predicts the quality of thetherapeutic alliance with adults (Horvath, 1994;Moras & Strupp, 1982). Furthermore, relationshipsrequire time to build. In MDFT, where therapistsperiodically work separately with individuals andfamily subsystems (siblings, parents), the strengthof the therapist-adolescent relationship may be, inpart, a function of the amount of time the two spendtogether in sessions.

Trained raters coded the extent to which thera-pists implemented proposed alliance-building be-haviors over the first three sessions of each case(30 sessions in all). Analyses were then conductedto examine the reliability with which raters couldcode the extensiveness of each item, the interrela-tionship between therapist interventions, and thepatterns in which therapist techniques were imple-

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mented over time in the improved and nonim-proved groups. We hypothesized that the alliance-building techniques identified in this study'sdiscovery-oriented stage would be implementedmore extensively in cases in which initially pooralliances improved.

ParticipantsSample. The 10 adolescents who participated

in this study were drawn from a sample of 48adolescents and their families referred for treat-ment of adolescent substance abuse. Treatmentwas conducted in an inner-city, university-basedclinic. Only adolescents who participated in atleast 10 minutes of each of the first three sessionsof therapy were eligible for inclusion. Five caseswere chosen that represented initially poortherapist-adolescent alliances that improved, andfive cases were chosen that represented initiallypoor therapist-adolescent alliances that did notimprove (see Procedures). The mean age of theadolescents was 15 (SD = 0.8), 70% were male,and 80% identified themselves as African Ameri-can. Seventy percent came from single-parenthomes and seventy percent came from homeswith annual family incomes of less than $35,000.

Therapists. The three therapists in the studyhad master's degrees in social work, with one alsoholding a doctorate in developmental psychology.One therapist was an African American female,one an African American male, and one a Euro-pean American female. Their average age was 44years (SD = 3). They each had 5 years of post-graduate clinical experience and more than 2years of family-therapy training and experience.All three therapists were trained in the manualizedMDFT approach for at least 3 months (10 hoursper week) prior to treating study cases.

Alliance raters. A group of 11 raters wastrained to code therapist-adolescent alliance. Thegroup consisted of graduate and undergraduatepsychology students. Their mean age was 22, and10 were female. They ranged from having zeroto having one year of clinical experience. Theraters included African Americans, Asian Ameri-cans, European Americans, one individual fromIndia, and one individual from Puerto Rico.

Therapist-behavior raters. A second group ofsix raters was trained to code therapist alliance-building behaviors. This group consisted primar-ily of doctoral counseling-psychology students.They ranged from having one year to having ex-tensive clinical experience. Their mean age was

26, and four were female. This group of ratersconsisted of one African American and five Euro-pean Americans.

Measures

Therapist-adolescent alliance. The therapist-adolescent alliance was assessed using two sub-scales of the Vanderbilt Therapeutic AllianceScale (VTAS) (Hartley & Strupp, 1983). TheVTAS is a 44-item, observer-rated instrument de-signed to measure the strength of the therapeuticalliance in individual therapy. Items include ques-tions such as, "To what extent did the patientindicate that he or she experiences the therapistas understanding and supporting him or her?";"To what extent did the therapist and patient worktogether in a joint effort to deal with the patient'sproblems?" Each item is rated on a Likert-typescale ranging from 0 (not at all) to 5 (a great deal).The full scale includes three subscales: TherapistContribution, Patient Contribution, and Therapist-Client Interaction. The VTAS has demonstratedacceptable interrater reliability and internal con-sistency in several studies (Hartley & Strupp,1983; Kamin, Garske, Sawyer, & Rawson, 1993;Krupnick et al., 1994). Furthermore, it showsconvergent validity with other common alliancemeasures (Tichenor & Hill, 1989).

We used only the 26 items from the PatientContribution and Therapist-Client Interactionscales. The Therapist Contribution scale waseliminated in order to distinguish between thera-pist techniques and the client's participation inthe alliance. Defining alliance as client collabora-tion, as distinct from therapist technique, hasboth empirical and theoretical advantages. First,the patient involvement component of the allianceconsistently emerges as the best predictor of out-come (Henry & Strupp, 1994). Second, distin-guishing between therapist techniques and thera-peutic alliance allows researchers to investigatethe relationship between these two variables(Frieswyk et al., 1986).

Therapist alliance-building behaviors. TheAlliance Building Behavior Scale (ABBS) (Dia-mond, Liddle, Dakof, Hogue, & Johnson-Leckrone, 1996) was developed to measure thera-pist behaviors. The ABBS includes descriptionsand exemplars of the six therapist alliance-building behaviors identified in the discovery-oriented phase of this study (see Table 1), alongwith descriptions and exemplars of two generictherapist behaviors. Two generic behaviors were

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TABLE 1. Alliance-Building Behavior Scale Items

Alliance-Building Behavior Description of Behavior Example

Attend to adolescent's experience. Therapist clarifies, summarizes, "It sounds like you've been responsibleinterprets adolescent's feelings, for yourself and your brother."thoughts, or behaviors.

Orient adolescent to the collaborative Therapist frames treatment as a vehicle "Your side of the story is just as importantnature of therapy. for addressing the teenager's concerns as your parents."

and aspirations.

Formulate meaningful goals. Therapist elicits therapy goals based on "You said your parents don't treat youadolescent's complaints and aspirations. respectfully. Is that something we can

talk about hereT'

Present self as an ally. Therapist indicates a willingness to "I will help your parents hear howadvocate for adolescent. humiliating it is for you to be yelled at."

Challenge control and contingency Therapist challenges adolescent's "You may not believe that your parentsbeliefs. negative sense of his or her agency. are going to listen to you, but there are

things you can do to help them takeyou seriously."

Address issues of trust, honesty, and Therapist emphasizes trust and "I'm not going to run and tell your parentsconfidentiality in the therapeutic confidentiality issues in a nondefensive what you say to me in here."relationship. fashion.

Generic Behaviors Description of Behavior Example

Gather information. Therapist uses questions to elicit "So, you guys are getting high beforeadditional information about school. How do you pay for thatT'adolescent's life.

Challenge cognitions and behaviors. Therapist challenges inconsistencies "You would like your mother to stopbetween adolescent's stated wishes or calling the school to 'check' on you, butgoals and his or her behaviors. you've cut every day this week."

included to insure that raters could not only reli-ably code alliance-building behaviors but couldalso reliably distinguish them from other, commontherapy techniques. Each therapist behavior is as-signed a global extensiveness score ranging from 0to 6 on a Likert-type scale. "Extensiveness" refersto the thoroughness and the frequency with whichthe intervention was implemented (Evans, Piasecki,Kriss, & Hollon, 1984; Hill, O'Grady, & Elkin,1992; Hogue et al., 1998).

Pretherapy interpersonal relations. The Self-Perception Profile for Adolescents (SPPA; Harter,1988) is a self-report instrument designed to as-sess adolescents' judgments of their competenceor adequacy in eight specific domains, as well asof their global self-worth. One of these domains,Social Acceptance, reflects adolescents' percep-tions of how easily they make friends, how popu-lar and accepted they are, and how likable they

feel. The Social Acceptance subscale was usedas a measure of interpersonal relations. Scores onthis scale range from 0 to 4. In prior studies onnonclinical populations, the Social AcceptanceScale subscale demonstrated high levels of inter-nal consistency, with Cronbach's alpha rangingfrom .77 to .90 (Harter, 1988).

Procedures

Measuring pretherapy levels of interpersonalrelations. The SPPA was administered as part ofa pretherapy assessment battery.

Coding alliance and defining the groups. Alli-ance raters received 15 hours of training on theVTAS. After attaining adequate interrater reli-ability, intraclass correlation coefficient [ICC( 2, 1)> .70] (Shrout & Fleiss, 1979), the raters codedthe first- and third-session alliance for all 48MDFT cases. Raters were assigned to code ses-

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sions according to a randomized block design(Fleiss, 1981). No rater coded more than onesession of a particular case, and raters were naiveto the purpose and hypotheses of the study.

From among the 48 total cases, the 21 lowestfirst-session alliance scores were identified ashaving initially poor alliance cases. From thisinitially poor alliance group, 5 cases were identi-fied as having alliances that improved by Session3, according to the following standards: Improvedalliances increased by at least one standard devia-tion (SD = 19.30) from Session 1 to Session 3and, as a group, had a mean third-session alliancescore (M = 91.4, SD = 13.78) that did notstatistically differ from the mean third-session al-liance score of the group of 27 cases with initiallyadequate alliances (M = 81.48, SD = 20.02;t(30) = 1.05, p < .29). From the remaining 16initially poor alliance cases, a group of 5 unim-proved alliances was identified as follows: Unim-proved alliances did not increase by a full stan-dard deviation from Session 1 to Session 3 and,as a group, had a mean third-session alliance(M = 56.1, SD = 17.60) that was significantlybelow that of the group of 27 initially adequatealliances (t(30) = -2.64, p < .01).

Coding alliance-building behaviors. Ratersreceived 20 hours of training on the ABBS. Afterattaining sufficient interrater reliability for eachbehavior item, ICC(2 6) > .60, raters coded thefirst three sessions of all ten study cases (30 ses-sions in total) according to a randomized blockdesign. Two raters coded each session (10 ses-sions per rater). No rater coded more than onesession from each case, and raters were naive tothe purpose and hypotheses of the study.

Results

Preliminary Between-Group Comparisons

Analyses were conducted to insure that the im-proved and unimproved alliance groups did notdiffer on initial alliance scores, adolescent's pre-therapy interpersonal functioning, and time spentwith therapist. There was no difference betweenthe improved (M = 64.4, SD = 15.0) and unim-proved (M = 60.7, SD = 19.7; t(8) = .33,p < .75) alliance groups on first-session alliancescore. Similarly, there were no differences be-tween the improved (M = 68 min., SD = 71min.) and unimproved (M = 68 min., SD = 45min.; t(8) = .00, p < .99) alliance groups in theamount of time therapists spent with parents and

adolescents together across the first three sessionsor the amount of time therapists spent alone withthe adolescent across the first three sessions(M = 70 min., SD = 32 min. vs. M = 55min., SD = 31 min.; t(8) = .77, p < .47).Furthermore, a comparison of mean scores on theSocial Acceptance subscale of the SPPA revealedno difference between the improved (M = 1.16,SD = 0.17) and the unimproved (M = 1.12,SD = 0.27; t(8) = .28, p < .78) groups regardingadolescents' pretherapy interpersonal functioning.

VTAS: Interrater Reliability and Scale Properties

Consistent with prior research on the VTAS,raters were able to achieve a high degree of inter-rater reliability. Raters achieved a mean ICC(,ll)of .80 for the scale as a whole. An internal con-sistency analysis performed on the 26 VTASitems produced a Cronbach's coefficient alphaof .95, suggesting that the two VTAS subscalesmeasure a single underlying construct defined asalliance. These results suggest that the VTAS isa reliable measure of therapist-adolescent alliancefor this population.

ABBS: Interrater Reliability and Scale Properties

In order to determine how reliably coders hadmeasured each type of therapist behavior, we cal-culated separate interrater correlation coeffi-cients(, 6) for each ABBS category. Except forchallenging control and contingency beliefs,which were clearly unreliable (ICC[,1 61 .08), theseven remaining therapist behaviors showed ade-quate reliabilities, with ICCs(1,6) ranging from .52to .74. Reliability estimates of this magnitude aretypical for studies of this nature, in which ratersare asked to provide global scores for complexand comprehensive therapist interventions (Bar-ber, Crits-Christoph, & Luborsky, 1996; Barber,Mercer, Krakauer, & Calvo, 1996; DeRubeis &Feeley, 1990; Startup & Shapiro, 1993). Becausethe behavior-challenge control and contingencybeliefs could not be reliably coded, it was elimi-nated from all subsequent analyses.

We then investigated whether the seven re-maining ABBS items were distinct. For example,can the behavior "Formulating personally mean-ingful goals" be distinguished from "Orientingthe adolescent to the collaborative nature of ther-apy"? In particular, we were interested in whetherthe five reliable alliance-building categories weremeasuring distinguishable, yet related constructsor whether they were each measuring a single,

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common alliance-building approach (e.g., a"good therapist effect"). We performed a correla-tional analysis to measure the relations betweenall seven ABBS items (five alliance-building andtwo generic). This analysis produced a Cron-bach's coefficient alpha of .29, which suggeststhat the seven ABBS items do not represent asingle underlying construct but, rather, reflectsomewhat distinct behaviors. Furthermore, Pear-son's correlations were computed to determinethe intercorrelations among all seven items. Afteremploying a Bonferonni correction, .0024 (.05/21), only one correlation (Trust, honesty, & con-fidentiality x Orient to the collaborative natureof therapy) was significant and positive. Theseresults support the contention that ABBS itemsrepresent somewhat distinct therapist interven-tions that can be measured independently. Thesmall sample size prohibited the use of factoranalytic techniques that might have further clari-fied the relationships between alliance-buildingbehaviors.

Exploratory Between-Group Analyses ofTherapist Behaviors

In order to examine the patterns in whichalliance-building behaviors were implementedacross the first three sessions of MDFT, andwhether these patterns distinguished between im-proved and unimproved alliances, five repeated-measure ANOVAS were performed. For eachANOVA, alliance status (improved vs. unim-proved) was the between-group factor, time wasthe repeated measure, and one of the five reliablealliance-building behaviors served as the depen-dent variable. Means are depicted in Figures 1-7.

Orient to collaborative set53

3 ----- -

2

0sssion I session 2 Assion 3

Figure 1. Orient to a collaborative set.

Gather information

S rssion I sesion 2 session 3

Figure 2. Gather information.

It is important to remember that our small samplesize significantly reduced the power of these anal-yses. Consequently, post-hoc analyses were lim-ited to a series of planned, pairwise t tests con-ducted at each of the three points (sessions) intime. In order not to capitalize on chance, a Bonf-eronni correction was employed and the p valuefor planned post-hoc t tests was set at .017 (.05/3). Because the nature of this study was explora-tory, results are reported as both p values andeffect sizes. Only significant p values and sig-nificant effects sizes are reported. For etasquared, effect sizes of .01 are considered small,.06 medium, and .16 large. For Cohen's d, effectsizes of .2 are considered small, .5 medium, and.8 large (Cohen, 1988). Reports of effect sizescan help uncover what may be clinically im-portant phenomena, such as the impact of thera-pist behaviors, that do not reach statistically sig-nificant levels because of low power (Cohen,1988).

Results showed a significant main effect fortime for addressing trust, honesty, and confiden-tiality in the therapeutic relationship, F(1,8) =6.45, p = .03, n2 = .65. Across both groups,therapists decreased the extent to which they em-phasized the sensitive and confidential nature ofthe therapeutic relationship across the first threesessions of treatment. Although the group by timeinteraction did not reach statistical significance,F(1,8) = 1.56, p = .27, n2 = .31, the effectsize was large. A visual inspection of the means(see Figure 7) suggests that, from Session 1 toSession 2, therapists more dramatically decreasedthe extent to which they addressed trust, honesty,

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Formulate goals5

3

i

0 I

;euron session 2 aussi

Figure 3. Formulate goals.

and confidentiality in the improved alliance groupthan in the unimproved alliance group.

Two interventions, orienting the adolescent tothe collaborative nature of therapy and attendingto the adolescent's experience, had main effectsfor time that evidenced large effect sizes, F(1,8) =2.74,p = .13, n2 = .44 andF(1,8) = 2.37,p =.16, n2 = .40, respectively. Across both groups,therapists decreased their use of orienting inter-ventions over time. In regard to attending to theadolescent's experience, the main effect is quali-fied by a group by time interaction that ap-proached significance and evidenced a particu-larly large effect size, F(1,8) = 4.25, p = .06,n2 = .55. The pairwise t test at Session 3 alsoevidenced a small to moderate effect size, t =1.99, p = .08, d = .32. By Session 3, therapistswere attending to the adolescent's experiencemore in the improved alliance group than in theunimproved alliance group. A visual inspectionof the means (see Figure 6) suggests that, whilein both groups the therapists increased their use ofthis behavior over the first two sessions, between-group differences evolved from Session 2 to Ses-sion 3. In the improved-alliance group, therapistscontinued to increase their attention to the adoles-cent's experience, whereas in the unimproved-alliance group, therapists decreased the extent towhich they attended to the adolescent's experi-ence.

The results for presenting as the adolescent'sally show a similar pattern. Although there wasa large effect for time, F(1,8) = 1.07, p = .39,n2 = .23, this effect must be interpreted in thecontext of the significant time by group interac-

tion, F(1,8) = 7.12, p = .02, n2 = .67. BySession 3, therapists were presenting themselvesas allies much more in the improved-alliancegroup than in the unimproved-alliance group,t = 2.76, p = .02, d = .55. A visual inspectionof the means (see Figure 5) suggests that, whereasin the improved-alliance group therapists dramati-cally increased their use of this intervention fromSession 2 to Session 3, by Session 3 therapists inthe unimproved-alliance group appeared to haveall but abandoned their attempts to present as theadolescent's ally.

Once again, a similar pattern appears for for-mulating personally meaningful goals. Althoughnot statistically significant, the time by group in-teraction bears a large effect size, F(1,8) = .83,p = .48, n2 = .19. Pair-wise t tests revealed asmall to moderate effect size at Session 3, t =1.88, p = .10, d = .30. By Session 3, therapistsin the improved-alliance group were helping ado-lescents to form personally meaningful goalsmore than therapists in the unimproved-alliancegroup. Much like the results for presenting asthe adolescent's ally, between-group differencesappear to be the result of an increase in therapists'focus on formulating personally meaningful goalsin the improved-alliance group and a decrease inthis intervention in the unimproved-alliance group(see Figure 3).

Discussion

This study represents a first step in articulatingand measuring developmentally based strategiesfor improving initially poor alliances with adoles-cents in family therapy. An iterative, discovery-

Challenge cognitions & behaviors.

;ession Session 2 session 3

Figure 4. Challenge cognitions & behaviors.

363

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-~~~~~~L~~~~~.

A


Present as an ally therapists listened carefully to teenagers, aninitially noor therapeutic alliance improved.

The fact that alliances improved when clini-cians helped the adolescent to formulate person-ally meaningful goals is syntonic with researchon client goal-setting behavior in adult psycho-therapy. The more adult clients are involved insetting the goals for therapy, the higher their levelof satisfaction with treatment (Willer & Miller,1976). DiGiuseppe and his colleagues suggestthat adolescents may be even more concernedthan adults about "agreement on the goals andtasks of therapy because of the importance of

session 2

Figure 5. Present as an ally.

oriented, observation-based methodologydetailed, narrative descriptions of sixbuilding interventions as they actuallyin family-therapy sessions. Raters wenreliably code the extent to which therapismented 5 of these interventions: orient a(to the collaborative nature of therapy; fpersonally meaningful goals; attend to thcent's experience; present self as an;address trust, honesty, and confidentiali

Results of exploratory between-groupsuggest that by the third session of therapists attended to the adolescent's experiesented themselves as the adolescent'shelped the adolescent formulate personalingful goals more extensively in casesthe alliance improved than in cases in valliance did not improve. The findingtending to the adolescent's experience iated with improved alliances complemersuits of earlier research with adults onattunement. Empathic resonance, defineing on the same wavelength" as the clas the client being "fully heard," has beto contribute to positive treatment outccadults (Orlinsky & Howard, 1986, p. 34"heard" may be particularly important tcents, in that self-expression is essentiatity formation and autonomy developmthermore, adolescents who abuse drevidence problem behaviors frequently d"heard," understood, or acknowledged.often socially ineffective and become eatrated in their conversations with adults& Block, 1990). This study suggests t

sessionn 3 developmental issues such as dependence, mde-pendence, and self-determination for teenagers"(DiGiuseppe et al., 1996, p. 87). Similarly, in ourclinical work we have found that the therapeuticalliance is enhanced when therapists, together

y yielded with the teenager, can identify a goal that makesalliance- therapy acceptable, or even desirable, to the ado-occurred lescent (Liddle, in press). We have not found ite able to helpful to assume that teenagers come to therapysts imple- to reduce their drug use or to find a way to im-dolescent prove their school performance. These mattersbrmulate may be important to parents or involved others,e adoles- but they are not necessarily important to the teen-ally; and ager (Liddle, in press). Improving initially poority. therapist-adolescent alliances may depend onanalyses helping the teenager define a personally meaning-

py, thera- ful treatment agenda.nce, pre- What most characterized improved alliancesally, and was the therapist's presentation of himself or her-ly mean- self as the adolescent's ally. When therapistsin which showed a willingness to advocate for teenagerswhich the and commit to helping them meet their goals,, that at-is associ-itsthere- Attend to experiencetherapistd as "be-lient, anden foundome with4). Beingo adoles-1 to iden-ent. Fur-rugs andlo not feelThey are

easily frus-(Shedler

hat when

5

4

2

n

session I session 2

5

4

3

2

1

0

;es&ion

,-I

364

Figure 6. Attend to adolescent's experience.

session 3

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Trust, honesty and confidentiality

Improved alliances-- Unim rond li.nc.

sessionn ssion 2

Figure 7. Trust, honesty, & confidentiality.

adolescents participated more fully in the thera-peutic process. Therapists' advocacy took manyforms, such as offering to meet with school offi-cials to help the teenager change a class or sup-porting the adolescent during negotiations withparents around issues such as curfew or respect.Further research is needed, however, to explorethe nature of the relationship between advocacyand the therapeutic alliance. Weisz (1986) sug-gested that teenagers' disbelief in their ability toinfluence change diminished their motivation toparticipate in treatment. Perhaps the promise of anunderstanding and influential adult ally generatedhope about the possibility of change and arousedadolescents' desire to engage in treatment.

These between-group differences appear to bethe function of contrasting trends in the two groups(see Figures 3, 5, and 6). While in improved-alliance cases, therapists increased their use ofalliance-building interventions from Session 2 toSession 3, therapists in the unimproved-alliancegroup decreased their use of these interventionsover the same time frame. In the improved-alliance group, therapists persevered in their ef-fort to build a collaborative relationship, while inthe unimproved-alliance cases, therapists ap-peared to have "given up." This contrast is mostevident in regard to presenting as the adolescent'sally. Because one cannot infer causality fromthese analyses, it is unclear whether therapistalliance-building behaviors led to improved alli-ances or were the function of improved alliances.It may be that increased adolescent participationand receptivity allowed therapists to aid in theformation of goals and attend to and advocate for

these teenagers. In any event, the decrement inthe use of alliance-building interventions in theunimproved-alliance group suggests how difficultit can be to manage the therapeutic relationshipwith clinically referred adolescents and under-scores the potential for negative therapist re-sponses to this challenge (Strupp, 1995).

Not surprisingly, therapists in both groupsplaced greater emphasis on therapy socializationinterventions such as orienting the adolescent tothe collaborative nature of therapy and definingthe confidential nature of the therapeutic relation-ship in the first session than in later sessions.Socialization to the treatment setting is naturallya first session task. One key differentiating featureof the improved vis-a-vis the unimproved-alliance group is the therapist's systematic pro-gression from therapy socialization interventionsto instrumental, action-oriented interventionssuch as goal formation and advocacy. These datasuggest that alliance building with clinically re-ferred adolescents is a two-step process. The firststep appears to involve transforming adolescents'negative expectations about treatment into thecredible promise of a collaborative endeavor. Thesecond step appears to be more agency-focusedand involves helping the teenager to recognizequickly what tangible benefit he or she can getout of therapy.

This study is a first step in developing anempirically based approach to improving therapist-adolescent alliances in family therapy. It'sstrengths include the following: a theory-guidedtherapy model based on current developmentalresearch; the reliable, rigorous measurement anddemarcation of improved versus unimproved alli-ances; the observation-based articulation of thera-pist alliance-building behaviors as they actuallyoccurred with adolescents in a manualized familytherapy; and the distinction between therapist be-haviors and the therapist-adolescent alliance.

At the same time, results of this study shouldbe interpreted cautiously. First, the results requirereplication using larger samples. Second, the cor-relational design does not allow for making causalinferences. For example, we cannot infer whethertherapist behaviors led to improved alliances orwhether client's increased participation in therapyelicited different behaviors from therapists. Ques-tions also remain as to whether improving alli-ances early in therapy with teenagers is associatedwith outcome at the end of treatment. This studyexamined the relationship between therapist inter-

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ventions and the alliance-building process. Re-search is also needed to explore the role of thetherapist-adolescent alliance in relation to thetherapist-parent alliance in family therapy. Fi-nally, the role of race requires further investiga-tion. This sample was primarily African Ameri-can. The question remains as to what degree theseresults are population specific. More studies areneeded to examine the interaction between race,therapist interventions, and adolescent engage-ment. For example, there is preliminary evidencesuggesting that the introduction of particular cul-turally relevant themes such as rage, alienation,respect, and journey from boyhood to manhoodmay help to engage African American, maleadolescents in family therapy (Jackson-Gilfort,Liddle, & Dakof, 1999). Such studies, in con-junction with this investigation of therapist alli-ance-building behaviors with teenagers, can ad-vance our understanding of what constituteseffective family therapy with clinically re-ferred adolescents.

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