Building Alliances with (In)Voluntary Clients: A Study Focused on Therapists’ Observable Behaviors

• DOI: http://doi.org/10.1111/famp.12265
• Published date: 01 December 2017
• Author: Valentín Escudero,Ana Paula Relvas,Diana Cunha,José Tomás Silva,Luciana Sotero
• Date: 01 December 2017

Building Alliances with (In)Voluntary Clients: A Study

Focused on Therapists’ Observable Behaviors

LUCIANA SOTERO*

DIANA CUNHA*

JOS

E TOM

AS DA SILVA*

VALENT

IN ESCUDERO

†

ANA PAULA RELVAS*

This study aimed to compare therapists’ observable behaviors to promote alliances with

involuntary and voluntary clients during brief family therapy. The therapists’ contribu-

tions to fostering alliances were rated in sessions 1 and 4 using videotapes of 29 fam ilies

who were observed in brief therapy. Using the System for Observing Family Therapy Alli-

ances, trained raters searched for specific therapist behaviors that contributed to or

detracted from the four alliance dimensions: engagement in the therapeutic process, an

emotional connection with the therapist, safety within the therapeutic system, and a share d

sense of purpose within the family. The results showed that when working with involun-

tary clients, therapists presented more behaviors to foster the clients’ engagement and to

promote a shared sense of purpose within the family. However, in the fourth session, the

therapists in both groups contributed to the alliance in similar ways. The results are dis-

cussed in terms of (a) the therapists’ alliance-building behaviors, (b) the specificities of each

client group, and (c) the implications for clinical practice, training, and researc h.

Keywords: Therapists; Therapeut ic Alliance; Involuntary Clients; Family Therapy;

System for Observing Family Therapy Alliances

Fam Proc 56:819–834, 2017

INTRODUCTION

There is evidence that the therapeutic alliance is one of the most robust relationship

factors that account for change in successful psychotherapy across different types of

therapy, clients, and problems (Fl€

uckiger, Del Re, Wampold, Symonds, & Horvath, 2012;

Friedlander, Escudero, Heatherington, & Diamond, 2011; Horvath, Del Re, Fl €

uckiger, &

Symonds, 2011). However, the literature suggests that forming an alliance with involun-

tary clients is particularly difficult (Friedlander, Escudero, & Heatherington, 2006;

Honea-Boles & Griffin, 2001; Relvas & Sotero, 2014; Snyder & Anderson, 2009). In other

words, allying with clients who have not asked for therapy and do not recognize the need

for or value of therapy is challenging (Ivanoff, Blythe, & Tripodi, 1994; Sotero & Relvas,

2012). These clients are generally referred to therapy through external agencies (e.g.,

schools, mental health services, child protective services, or the courts). In contrast, volun-

tary clients are characterized by a self-initiated appeal for help (i.e., the client seeks

*Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal.

†

Department of Psychology, University of A Coru~

na, A Coru~

na, Spain.

Correspondence concerning this article should be addressed to Luciana Sotero, Faculty of Psychology

and Educational Sciences, University of Coimbra, Rua do Col

egio Novo, 3001-802 Coimbra, Portugal.

E-mail: lucianasotero@fpce.uc.pt.

819

Family Process, Vol. 56, No. 4, 2017 ©2016 Family Process Institute

doi: 10.1111/famp.12265

therapy without an external referral). These clients are often willing to engage with the

therapist and form an alliance, and they are motivated to collaborate to make changes

through therapy (O’Hare, 1996; Prochaska, Johnson, & Lee, 2008). Therefore, the notion

of an “involuntary client” refers to both the institutional referral and the clients’ unwill-

ingness to be in therapy (Sotero, Major, Escudero, & Relvas, 2016). A subset of involuntary

clients comprises those who are legally referred to therapy (by the court or state agencies)

and who face legal consequences if they leave therapy—mandated clients (Rooney, 2009).

In contrast, the term “voluntary clients” reflects the self-referral and the clients’ willing-

ness to be in therapy. However, the distinction between involuntary and voluntary clients

is more complex in the context of couple and family therapy than in individual therapy

(Friedlander, Escudero, & Heatherington, 2006). In fact, in each family, members fre-

quently have different motives, distinctive motivational levels, and/or different goals for

therapy, irrespective of the source of the referral. Consequently, this study defines volun-

tary clients as those families self-referred to therapy with any family member expressing

unwillingness to be in therapy; in contrast, families referred to therapy by an Institution

or Agency and with at least half of the family members expressing not wanting to be in

therapy are defined as involuntary clients.

Thus, this study follows the lead of a previous study of involuntary clients’ observable

behaviors that reveal the strength of the alliance in brief family therapy. In the first

study, we examined the ways in which involuntary clients establish the therapeutic alli-

ance in the first and fourth sessions in comparison with voluntary clients (Sotero et al.,

2016). The results showed that families that are pressured to attend therapy and are

referred by a third party have significantly weaker alliances than voluntary clients in the

first session. Nevertheless, these differences in alliance strength between involuntary and

voluntary families tend to disappear in the fourth session. The results generally suggest

that despite the initial differences in the strength of alliances, the therapeutic process

seems to promote some convergence between involuntary and voluntary clients in terms

of alliance behaviors (Sotero et al., 2016). In this study, we want to compare the thera-

pists’ observable alliance-related behaviors with involuntary and voluntary families in the

first and fourth sessions.

Surprisingly, many therapists work with involuntary families, but little attention has

been given to the challenges of providing interventions under these circumstances (Snyder

& Anderson, 2009). One such challenge is the establishment of effective therapeutic alli-

ances. Thus, although the client’s motivation prior to treatment can be an essential factor

in facilitating the therapeutic process and eventually the therapeutic change, what thera-

pists do in therapy has an impact on the extent to which families become engaged in the

process (Sprenkle, Davis, & Lebow, 2009). Despite the vast literature about the therape u-

tic alliance, we know little about in-session therapist behaviors that contribute to this alli-

ance (Crits-Christoph, Gibbons, & Hearon, 2006). “How do in-session therapist beh aviors

contribute to strong and weak alliances with couples and families?” is undoubtedly an

essential research question; however, only a few studies approached that question, and

they used quite different research designs. One study (Thomas, Werner-Wilson, & Mur-

phy, 2005) using the Working Alliance Inventory-Couples (Symonds & Horvath, 2004),

and another five studies, using the same instrument utilized in the present study, the Sys-

tem for Observing Family Therapy Alliances (SOFTA; Friedlander, Escudero, Horvath,

et al., 2006), assessed therapists’ alliance-related behaviors within sessions (Escudero

et al .,2012; Friedlander, Lee, Shaffer, & Cabrera, 2014; Lambert, Skinner, & Friedlander,

2012) or within cases over time (Friedlander, Lambert, Escudero, & Cragun, 2008; Mu~

niz

de la Pe~

na, Friedlander, Escudero, & Heatherington, 2012). One of those studies found

that stable and deteriorating alliances were reflected in the relational control dynamics

observed between therapists and their adolescent clients (Mu~

niz de la Pe~

na et al., 2012);

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