Therapists’ and Clients’ Perceptions of Bonding as Predictors of Outcome in Multisystemic Therapy®

• Published date: 01 December 2018
• Author: Elizabeth A. Whitmore,Patricia A. Brennan,Phillippe B. Cunningham,Sharon L. Foster,Tatiana Glebova
• DOI: http://doi.org/10.1111/famp.12333
• Date: 01 December 2018

Therapists’ and Clients’ Perceptions of Bonding as

Predictors of Outcome in Multisystemic Therapy

â

TATIANA GLEBOVA*

SHARON L. FOSTER

†

PHILLIPPE B. CUNNINGHAM

‡

PATRICIA A. BRENNAN

§

ELIZABETH A. WHITMORE

¶

This longitudinal study examined whether strength of and balance in self-reported care-

giver, youth, and therapist emotional bonds in mid- and late treatment predicted outcomes

in Multisystemic Therapy of adolescent behavior problems in a sample of 164 caregiver-

youth dyads. Strength of and balance in bonds related to outcome in different ways,

depending on the source of the report and time. Results showed a limited association

between family members’ emotional connection with the therapist and treatment outcome,

whereas therapists’ perceptions of bond with the caregiver showed highly significant asso-

ciations across time. Caregiver-therapist agreement on emotional connection at both time

points predicted therapist evaluation of treatment success and successful termination, but

this was largely explained by therapists’ level of alliance. Balance in bonds with the thera-

pist between caregiver and youth had no significant associations with any outcome. The

study major limitations such as examining only one component of alliance and possible

implications are discussed.

Keywords: Alliance; Bond; Perception; Multisystemic Therapy

Fam Proc 57:867–883, 2018

The therapeutic alliance has been referred to as the “quintessential integrative vari-

able” in psychotherapy (Wolfe & Goldfried, 1988), and is one of the most-often cited

common factors in psychotherapy process (e.g., Davis, Lebow, & Sprenkle, 2012; Karver,

Handelsman, Fields, & Bickman, 2005). Meta-analytic studies have found modest but con-

sistent relationships between alliance and outcome across adult treatments and clinical

problems (e.g., Fluckiger, Del Re, Wampold, Symonds, & Horvath, 2012; Friedlander,

Escudero, Heatherington, & Diamond, 2011). At the same time, the alliance-outcome asso-

ciation in youth therapy appears to vary across studies and treatments (Karver,

*Couple and Family Therapy Program, Alliant International University, Sacramento, CA.

†

Alliant International University, San Diego, CA.

‡

Family Services Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of

South Carolina, Charleston, SC.

§

Department of Psychology, Emory University, Atlanta, GA.

¶

Synergy Outpatient Services, University of Colorado School of Medicine, Aurora, CO.

Correspondence concerning this article should be addressed to Tatiana Glebova, Couple and Family

Therapy Program, Alliant International University, Sacrmento, CA. E-mail: tglebova@alliant.edu.

Multisystemic Therapy is a registered trademark of MST Group, LLC.

The third author is a paid consultant of MST Services and is part owner of Evidence Based Services, Inc.,

a MST Network Partner Organization. Preparation of this article was funded in part by grant

R01MH068813 from the National Institute of Mental Health. The authors are grateful to Angi Wold and

the research assistants who collected the data. Steve Shapiro provided data management.

867

Family Process, Vol. 57, No. 4, 2018 ©2017 Family Process Institute

doi: 10.1111/famp.12333

Handelsman, Fields, & Bickman, 2006) and may be moderated by problem type, treatment

mode, and other variables (McLeod, 2011). This warrants more studies of the alliance-out-

come nuances in different treatments focused on youth.

Most conceptualizations of therapeutic alliance and its measurement include two pri-

mary components: “task and goal oriented” and “bond” (Elvins & Green, 2008; Webb et al.,

2011). “Bond” refers to the relational aspect or emotional connection and trust between cli-

ent and therapist, whereas the “task” component of alliance pertains to agreement on the

goals and methods of treatment. While there is a consensus that therapist-client bond is a

key ingredient in therapeutic process (e.g., Norcross & Wampold, 2011), it is rarely stud-

ied separately from task aspects of alliance in the context of youth evidence-based treat-

ments. Karver et al. (2006) concluded their meta-analysis of associations between

therapeutic relationship variables and treatment outcomes in youth treatments with the

suggestion that combining alliance components in one measure may result in loss of infor-

mation about therapy process and different components may be differentially important

at different stages of treatment. They suggested that more research is needed to discover

the specific role of the bond component.

Affective bond, trust, and a sense of collaboration between the therapist and clients are

important components of alliance (Kindsvatter & Lara, 2012; Rait, 2000). The client’s rela-

tionship with the therapist may have a direct curative effect as well as play a mediating

role in increasing participation in treatment (Shelef, Diamond, Diamond, & Liddle, 2005)

and/or other therapy processes that lead to positive outcome (Karver et al., 2005). Estab-

lishing and sustaining a trusting and collaborative relationship with the therapist are con-

sidered to be both critical and especially challenging in treatments of youth externalizing

behaviors since youth are usually mandated to treatment or treatment is initiated by

adults (Shelef et al., 2005). This challenge may be present in individual treatment but be

especially difficult in family based treatments in which the therapist interacts with multi-

ple family members who come to therapy with different motivations, expectations, and

goals.

Family therapists have long acknowledged that the role of alliance requires considera-

tion of additional complexities and dimensions in family treatment: group level (the thera-

pist’s relationship with each subsystem and with the family as a whole) and within-family

alliance (the shared sense of purpose among family members; see Friedlander et al.,

2011). Simultaneously, a therapist forms a therapeutic relationship with each family

member, resulting in multiple individual alliances that may interact synergistically over

the course of treatment to enhance or undermine the overall family therapist alliance

(Pinsof, 1994). Each form of alliance may matter and impact treatment process and out-

come (Kindsvatter & Lara, 2012). Consideration of individual alliances can be especially

important in modalities that include both individual and family sessions. An unbalanced

alliance (also referred to as discrepant or split alliance; Bartle-Haring, Glebova, Gang-

amma, Grafsky, & Ostrom Delaney, 2012; Friedlander et al., 2011; Muniz De La Pena,

Friedlander, & Escudero, 2009; Robbins, Turner, Alexander, & Perez, 2003) occurs when

family members differ in their strength of alliance with the therapist. Robbins and col-

leagues (Robbins et al., 2003, 2006, 2008) examined within-family differences in alliance

in the context of Brief Strategic Family Therapy (BSFT), Functional Family Therapy

(FFT), and Multidimensional Family Therapy (MDFT) for adolescents with subst ance

abuse or behavioral problems. Robbins et al. (2003, 2006, 2008) found that balance in alli-

ance across family members early in treatment significantly predicted retention in BSFT,

FFT, and MDFT. Their findings also suggested that different dimensions of alliance may

affect treatment in different ways for different family based treatment models. Specifi-

cally, balance in alliance predicted retention in family therapies that work mostly in a con-

joint format (BSFT, FFT), whereas the strength of alliance (rather than balance) predicted

www.FamilyProcess.org

868

/

FAMILY PROCESS