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Section 3
Couples Therapy, Optimizing the Therapeutic Alliance

CEU Question 3 | CEU Test | Table of Contents | Couples
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In the last section, we discussed three common types of marriages in which the couple has chosen togetherness over intimacy.  These three types of marriages are the parent-child marriage, the stormy marriage, and the "perfect" marriage.

In this section, we will discuss a research study into factors that influence the development of an optimized therapeutic alliance during conjoint therapy for couples dealing with marital conflict.

Although the role of the therapeutic alliance in individual therapy has been given much attention in literature, there has been relatively little examination into the role and effect of the alliance in conjoint therapy. Clearly, one reason for this may be that the development of a therapeutic alliance in multiclient therapy is potentially far more complex. Thus the role, development, and course of the alliance in conjoint therapy are less well understood.

Dianne Symonds of Kwantlen University College and Adam Horvath recently conducted a study into factors influencing the therapeutic alliance in conjoint therapy. Symmonds and Horvath gathered information from 44 couples undergoing conjoint therapy.  The study focused on concerns regarding optimizing the alliance in conjoint therapy so as to increase the chance of positive change in the patterns in the clients’ relationship. The optimized alliance also may increase both partner’s responsiveness to new communication strategies.

As a lead-in to their research findings, Symmonds and Horvath offer the following case study:

Brandon, a middle aged accountant states that he has come to therapy because he is tired of arguing with his wife. Alice, a teacher, states that there is little intimacy in her relationship to Brandon, and wants their intimacy to improve. During the initial session, Brandon admitted that Alice had threatened to leave him if he did not come to therapy.

Brandon stated, "The real problem here is that Alice is too emotional. Everything makes her fly off of the handle." Alice then stated that something must be wrong with her, because she cannot control her emotions when they disagree. After hearing this, Brandon stated, "Well, if that’s the problem, shouldn’t Alice just continue therapy by herself? Why do I need to be here?" Clearly, Brandon and Alice had dissimilar ideas about the goals for therapy, which introduced tension into their therapy sessions. Do Brandon and Alice remind you of a couple you may be treating?

Development of an Optimized Therapeutic Alliance - 4 Influencing Factors

1. Allegiance & Alliance
As you know, Alice and Brandon had a problem with their allegiance. The first significant finding of Symmonds and Horvath’s study concerned two interrelated meaningful relationship within conjoint therapy, allegiance and alliance. Symmonds defined allegiance as the ongoing relationship between the partners regarding the therapy. Alliance, of course, is defined as the working therapeutic relationship between the partners and the therapist. Symmonds found that the impact of the nature of the allegiance between the partners could greatly complicate the development of an alliance with the therapist.

Symmonds, therefore, states that the way that the therapist responds to and participates in the process of reconciling the relationship of these two may be crucial for the development of a working therapeutic relationship. Clearly, if the dynamics of conjoint therapy create situations in which the client's loyalty to his or her partner (the allegiance) comes into conflict with the demands of the therapeutic alliance, this may negatively impact the outcome of the conjoint therapy. A conflict between the couples’ allegiance and the therapeutic alliance may also negatively impact the development of a working therapeutic relationship.

2. Unbalancing
A second significant finding of Symmonds and Horvath’s study concerns what occurs when one client’s alliance with the therapist is stronger than that of their partner. Symmonds and Horvath found that this unbalancing had a strong impact on the outcome of the therapeutic relationship. Of course, it is not uncommon for clients like Brandon and Alice to come to therapy with divergent conceptions of their problems and different goals for the therapy.

The study also points out that each partner may attempt to enlist the therapist to understand the issue sympathetically from his or her own perspective. Symmonds states that the extent to which each partner feels the therapist accepts his or her version of the problem and preferred outcomes as the goals of treatment influences how strongly the therapeutic alliance is formed. The study found that this process of attempting to gain the sympathy of the therapist may replicate the relationship dynamics that brought the couple in to treatment.

According to Symmonds and Horvath, this attempted co-opting of the counselor may lay the blame for the problem on the other partner, and damage the therapeutic allegiance between the couple. As a result, the couples in the study would perceive the alliance as unbalanced, resulting in a more negative outcome.  Symmonds and Horvath observed that a therapist in this situation would then need to balance building a strong alliance with each partner against the strain this would impose on the therapeutic allegiance.

The results of the study indicated that if the therapist was able to resolve this dynamic by moving from an "either/or" position to a "both/and" position, the therapeutic alliance to both partners was strengthened. Switching from an either/or position to a both/and position also resulted in stronger agreement between the partners regarding the nature of the alliance and the goals of the therapy.

3. Implications of a Disagreement
In addition to findings concerning alliance and allegiance, and unbalancing in conjoint therapy, a third finding of Symmonds and Horvath’s study concerned implications of a disagreement of the partners regarding the strength of the therapeutic alliance. The research found that a disagreement between partners regarding the strength of the therapeutic alliance may mean that the partners were working in different directions or had dissimilar levels of engagement in the tasks of therapy.

Disagreement between partners regarding the strength of the therapeutic alliance also could indicate that the couple had disparate levels of trust in the therapist’s ability to help them. The findings of the study indicated that these factors had a negative impact on the outcome of conjoint therapy. Symmonds and Horvath did find evidence that resolution of this dilemma could provide a good model for the couple in regards to dealing with other issues in their marriage. This was evidenced by the fact that couples who disagreed about the strength of the alliance at the third session of the study, but were able to come to an agreement before termination, had more positive outcomes than those who did not come to an agreement.

4. Gender Differences
A fourth finding of Symmonds and Horvath’s study concerned gender differences in the perception of the strength of the therapeutic alliance. Symmonds and Horvath found that if the male partner’s alliance was stronger, the conjoint therapy was more likely to have a positive outcome than if the female partner’s alliance was stronger. According to the study, one possible reason for this outcome may have been that male clients were in general more reluctant to come to therapy. As a result, if the therapist successfully fostered the engagement of this unwilling partner, the chances for a positive outcome were enhanced.

Symmonds hypothesized that these men may have been more reticent as they felt they had less ability to exert their influence within the context of the dynamics of an intimate interpersonal relationship.  The study also suggested that if female partners were more motivated to begin therapy, they were more able to work towards positive outcomes regardless of the strength of their alliance with the therapist. A further possible explanation for the finding may have been that a strong therapeutic alliance with the male partner provided compensation for a weak allegiance between the partners.

Symmonds and Horvath concluded that regardless of the reason for the results, the findings of their study suggest that if a therapist has to "risk" straining the relationship with one of the partners, the failure to have a strong alliance with the male partner may have more negative consequences.

In this section, we have discussed a research study into factors that influence the development of a working therapeutic alliance during conjoint therapy for couples dealing with marital conflict.

In the next section, we will discuss four specific patterns by which couples commonly undermine communication. These four patterns are escalation, invalidation, negative interpretations, and withdrawal and avoidance.

- Symonds, D., PhD., & O Horvath, A., EdD. (Dec 2004) Optimizing the Alliance in Couple Therapy. Family Process, 43(4), 443.

Peer-Reviewed Journal Article References:
Allen, J. G. (2014). Beyond the therapeutic alliance. Spirituality in Clinical Practice, 1(4), 263–265.

Escudero, V., Boogmans, E., Loots, G., & Friedlander, M. L. (2012). Alliance rupture and repair in conjoint family therapy: An exploratory study. Psychotherapy, 49(1), 26–37.

Kuster, M. (Oct 2017). Approach-avoidance goals and relationship problems, communication of stress, and dyadic coping in couples. Motivation & Emotion41(5), 576-590.

Munder, T., Flückiger, C., Gerger, H., Wampold, B. E., & Barth, J. (2012). Is the allegiance effect an epiphenomenon of true efficacy differences between treatments? A meta-analysis. Journal of Counseling Psychology, 59(4), 631–637

Online Continuing Education QUESTION 3
If the therapist must "risk" straining the therapeutic relationship with one partner, failure to have a strong relationship with which partner runs a greater risk of negatively affecting the outcome of conjoint therapy? To select and enter your answer go to CEU Test.

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