Journal of Marital and Family Therapy doi: 10.1111/jmft.12097 October 2015, Vol. 41, No. 4, 389–400

TARGETING THREATS TO THE THERAPEUTIC ALLIANCE: A PRIMER FOR MARRIAGE AND FAMILY THERAPY TRAINING Eli A. Karam University of Louisville

Douglas H. Sprenkle Purdue University

Sean D. Davis Alliant International University

Although theory and research highlight the importance of the client–therapist relationship, marriage and family therapy (MFT) training has historically centered on specific models, consisting of proprietary language and techniques, instead of common factors like the therapeutic alliance. In this article, we begin by making an argument for explicitly focusing on the therapeutic alliance in MFT training programs. Next, we highlight common alliance threats experienced by both faculty members and student therapists. We then integrate researchinformed principles with clinical wisdom to outline specific recommendations and concrete skill-building exercises for MFT educators and supervisors to use with their students to address these threats and advance training on the therapeutic alliance.

As marriage and family therapy (MFT) researchers continue their search for common mechanisms of change among different systemic models, significant work has been done to understand the role of the therapeutic alliance (Sprenkle & Blow, 2004a). This relationship has been deemed by most a necessary, but not sufficient ingredient in all successful psychotherapies (Bordin, 1979). The therapeutic alliance has been clearly established through meta-analyses as a strong predictor of outcome in psychotherapy across diverse treatment orientations and modalities (Horvath & Bedi, 2002; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). In relationship to alliance, positive correlations with outcome have been observed in the following systemically based theoretical orientations: in integrative problem-centered therapy with couples (Knobloch-Fedders, Pinsof, & Mann, 2004), in family therapy for at- risk youth (Robbins, Turner, Alexander, & Perez, 2003), in emotionally focused therapy (EFT; Johnson & Talitman, 1997), and in therapy “as usual” in private practice settings (Symonds & Horvath, 2004). Although therapeutic alliance has been described in a variety of different ways, we will focus on Bordin’s (1979) panthoretical conceptualization of it as composed of three distinct content dimensions: tasks, goals, and bonds. The first of these dimensions, tasks, targets therapist and client agreement on the process and structure of therapy. The second dimension, goals, refers to client and therapist consensus on the preferred outcomes of therapy. The bonds dimension captures the empathetic connection therapist and client. When there is high agreement on tasks, goals, and bonds between all interpersonal subsystems of the therapeutic system, alliances will be strong. When there is disagreement on these dimensions, however, the therapeutic alliance is weakened and intervention is needed to repair the therapeutic relationship.

Eli A. Karam, PhD, Marriage and Family Therapy Program, The Kent School of Social Work at the University of Louisville; Douglas H. Sprenkle, PhD, Marriage and Family Therapy Program, Department of Child Development and Family Studies, Purdue University; Sean D. Davis, PhD, Marital and Family Therapy Program, Alliant International University–Sacramento Campus. Address correspondence to Eli A. Karam, Family Therapy Program, Kent School of Social Work, Louisville, Kentucky 40292; E-mail: [email protected]

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In individual therapy, the alliance has been defined almost exclusively as the relationship between the client and therapist. A more systemic conceptualization that takes into account the relational complexities inherent to having more than one client present in the therapy room, however, is necessary to understand better the therapeutic alliance in the practice of MFT. To address this issue, Pinsof (1995) articulated several interpersonal dimensions of the therapeutic relationship. The interpersonal system of the Integrative Psychotherapy Alliance includes the following four domains: (a) Self-therapist (“the therapist and me”); (b) Other-therapist (“the therapist and my significant other or another family member”); (c) Group-therapist (“the therapist and my partner/family and myself”), and (d) Within System (“my partner/family members and I together without the therapist”). Therapists must able to identify and track these interpersonal subsystems with all of their cases to understand the full range of the therapeutic alliance. Although theory and research highlight the importance of this client–therapist relationship, MFT training has historically centered on specific models, consisting of proprietary language and techniques, instead of common factors like the therapeutic alliance (Sprenkle, Davis, & Lebow, 2009). We believe that although some therapists may have more natural ability in this area than others, building an alliance is nevertheless a process that can be improved upon through specialized attention and practice. In this article, we begin by making an argument for increasing the emphasis on the therapeutic alliance in MFT training programs, while also exploring common alliance threats experienced by both faculty members and student therapists. Moving beyond traditional primers and literature reviews on the subject matter, we then offer specific suggestions that MFT educators and supervisors may use to address these problems and advance the training on the therapeutic alliance.

INCREASING THE EMPHASIS ON THE THERAPEUTIC ALLIANCE IN MFT TRAINING PROGRAMS There are several important reasons for increasing the emphasis on the therapeutic alliance in MFT training programs. First, treating the alliance as a teachable construct could debunk the argument that common factors are too general and not organized enough to be translated into teachable components (Sexton & Ridley, 2004). Other current MFT educators have stressed that the emphasis on teaching of specific models should be complemented by training in these more universal common factors of psychotherapy (Blow, Sprenkle, & Davis, 2007; Fife, Whiting, Bradford, & Davis, 2014; Sprenkle et al., 2009). Secondly, learning about the therapeutic alliance is a good fit for the developmental skill level of the therapist-in-training. Focusing on core, straightforward strategies to build healthy therapeutic relationships may reduce anxiety for students struggling with mastering the complexity of a specific model or a challenging family system. Pinsof (1995) argues that, given the primacy of the alliance to successful outcomes, attention to the quality of the alliance should take priority over specific techniques or theory-driven interventions. If young therapists are confident in their ability to build and maintain these strong working relationships, then self-confidence issues around youthful appearance or lack of professional experience may be minimized. Thirdly, understanding how the alliance contributes to therapy outcome is part of becoming a research-informed clinician (Karam & Sprenkle, 2010). The importance of the alliance has been expanded on through the empirically supported lens of the meta-analysis. Possibly, the most robust finding in all of psychotherapy research history is the conclusion that the largest portion of outcome variance in therapy is due to common factors of change like the therapeutic alliance (Luborsky, 1976; Wampold, 2001). While there is strong support for the overall effectiveness of MFT, there is not yet overwhelming evidence for the relative effectiveness of the various models vis-
a-vis each other (Shadish & Baldwin, 2003). Knowing this information helps therapists realize they need not make a premature commitment to the superiority of any one model, but instead may look for and master the commonalities, like the therapeutic alliance, inherent to all effective models. Fourthly, specialized emphasis should be given to this construct in MFT programs due to the complex nature of alliances inherent to conjoint therapy. Simply envisioning the alliance as a distinct relationship that occurs between one client and one therapist is insufficient from a family 390

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systems perspective. This singular conceptualization obscures the multifaceted dimensions of MFT and diminishes different clients’ perspectives within the system on the same therapy (Helmeke & Sprenkle, 2000). For instance, a MFT working with a couple is contending with at least four different alliances relationships (therapist–husband, therapist–wife, therapist–husband and wife together, husband and wife together without therapist). Student therapists must learn strategies to identify, track, and attend to these interpersonal subsystems to stay balanced or avoid a split alliance (Pinsof, 1995). Finally, explicitly teaching about this essential therapeutic relationship may help young therapists improve damaged alliances. Several studies have reported the effectiveness of implementing techniques aimed at both building and repairing the therapeutic alliance in individual therapy (Crits-Christoph, Connolly Gibbons, Narducci, Schamberger, & Gallop, 2005; Safran et al., 2002; Whipple et al., 2003). Not only could specific alliance training improve client engagement in the critical first few sessions of therapy (Sprenkle et al., 2009), but it may also prevent early dropout (Whipple et al., 2003). The following alliance threats and suggested solutions are intended to aid educators in integrating therapeutic alliance training throughout all teaching, supervisory, and clinical components of MFT programs.

ALLIANCE THREATS AND SUGGESTED SOLUTIONS FOR MFT EDUCATORS Threat #1: A Lack of Confidence The scenario: The student therapist is academically sound, but loses confidence in forming bonds when working with older client systems. Research on therapist behaviors indicates that personal characteristics like warmth, flexibility, and accurate interpretation are positively associated with strong therapeutic bonds (Ackerman & Hilsenroth, 2003). In a qualitative account of pivotal moments in couples therapy, Helmeke and Sprenkle (2000) discovered that clients regarded therapist empathy as an essential component of the therapeutic bond. Humor and levity have also been demonstrated to increase the bond in clients that can laugh about their problems with therapists who are comfortable displaying their light-hearted side. Humor may also reduce tension and facilitate emotional release in the therapy room (Carroll & Wyatt, 1990). Conversely, certain therapist characteristics and behaviors may constrain the ability to form healthy bonds (e.g., rigidity, criticalness, inappropriate self-disclosure; see Ackerman & Hilsenroth, 2001). Fife et al. (2014) recently introduced the concept, way of being, to the alliance literature. Therapists can either be in the moment and genuinely engaged with the humanity of the client system or removed and impersonal when in the therapy room. If young therapists are trying too hard to be professional or appear more experienced than they really are to make up for their perceived inadequacies, they may lose the ability to remain present, relaxed, and responsive to the needs of the client system. They start to view their clients like case studies in their text books, rather than real people who may have many of the same fears and insecurities as they do. Suggested solution: Receive supervisor and group feedback on “way of being” with different modalities and client systems. While the practice of student therapists recording and critiquing their own performances is not new, the question of what to look for or evaluate while reviewing recorded therapy is often left open. To help supervisees gauge their way of being, the supervisor may structure this self-examination by asking students to select segments of tape where they felt fully present and connected with their clients. The supervisor may also ask the trainees to highlight portions of the session when they were too much in their head, over-focused on their anxiety or performance instead of connected to the client’s experience. In a variation on this exercise, during live supervision, the supervisor instructs the team members behind the mirror to code for vital therapist characteristics like humor, warmth, and empathy. By providing encouraging feedback, group members may help to build supervisee confidence and comfort. If there is corrective feedback to share during or after the live session concerning the student’s way of being, the supervisor may be best able to frame the comments in a way that does not threaten or further damage therapist confidence. Both supervisors and group members should always pay close attention to see whether way of being changes via a function of the modality of October 2015

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the therapy. For example, a student therapist who is in a comfort zone while working with individuals may become more reticent or removed from the experience when conducting couple or family therapy. Threat #2: Lack of “Liking” The Scenario: The student therapist does not have a strong liking or bond with either individual members or the entire client system. While it does not take years of experience or extensive knowledge of theory to make an authentic connection with a client system, bonds may not always be easy to form. Some clients enter therapy more motivated to change and are inherently more likeable than others. Alternately, each member of the system may be likeable on an individual basis, but when put together in couples or family therapy, the conflict and acrimony may make it harder to develop a bond with the client system as a whole. Suggested solution: Define therapeutic role. To strengthen and nurture the bond, therapists must define their role by explicitly reminding the couple or family that their alliance is with entire system, not just the individual (Pinsof, 1995). While it may be unavoidable to be inducted into the chaos of the family system, MFTs may diminish their ability to form bonds if they begin to function in the role of judge or jury. Therapists should assert that they are not there to be swayed or join with one spouse or family member against the other. This does not mean, however, that therapists should not advocate for someone in the system when another member is clearly wrong or outof-line. In taping their first sessions with couples or families, students should bring into supervision segments where they define their role for the system in order to get feedback both from the supervisor and other team members. In a classroom setting, it may also be beneficial to practice this skill in role play form with two students acting like a conflictual couple and another student playing the real life role of a firm and direct therapist who demonstrates an engaged and hopeful advocacy for the good of the greater system. Suggested solution: Develop curiosity for members of the client system. Therapists should also explore personal constraints that inhibit the ability to form bonds. We believe that if you do not automatically “like” your clients, you must at least learn to be curious about them. It is helpful to keep the following questions in mind as you attempt to nurture bonds: (a) What about the client’s presentation triggers you? Is it your issue or their issue?; (b) What underlying abilities or strengths does the client exhibit?; and (c) What keeps the client stuck in the same pattern or engaging in repeated behaviors that they know are not beneficial to their individual or relational health? To foster the bond dimension of the alliance, therapists must learn to share genuine feelings of hope and strength within the system without minimizing client deficits or constraints. These skills should be practiced both in therapy and in supervision. Threat #3: A Lack of Feedback The scenario: The student therapist does not have a good method to measure the alliance or track changes in the relationship with client system. The alliance is formed by a complex interpersonal interaction between the therapist and client system. Without specifically checking in with their clients on a regular basis, many MFTs may assume that clients feel the same way about therapy as they do. Although therapists may see their view of the therapeutic relationship as accurate, past research strongly indicates that the “client knows best” as it relates to accurate alliance ratings (Bachelor, 1995; Horvath, 1994). If young or inexperienced therapists fear unfavorable comments or would rather function primarily in an empathic listening role, they may never learn the appropriate skills necessary to initiate a conversation with the client system designed to elicit verbal feedback on this important alliance relationship. Given that therapists’ ratings of the alliance may often be incongruent from their clients’ views, Castonguay, Constantino, and Grosse Holtforth (2006) argue that therapists should routinely use empirically supported alliance measures to get feedback on this important relationship. Two computer-based feedback systems, the Systemic Inventory of Change (STIC; Pinsof et al., 2009) and the System for Observing Family Therapy Alliances (SOFTA; Friedlander et al., 2006) have been developed to serve as both clinical and research tools. Similar systems for tracking therapy outcomes and comparing them with norms have been

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used to relay clinically relevant information to therapists when their clients are responding poorly to treatment (Lambert et al., 2003). Whipple et al. (2003) examined the impact of providing therapists with feedback on various client-rated dimensions (including the quality of the alliance) and recommended clinical support tools to address problems in the therapeutic relationship. As compared with the no-feedback control group, clients in the feedback plus clinical-support-tools group attended more sessions, displayed less deterioration, and demonstrated higher recovery rates. Similarly, Lambert, Hansen, and Finch (2001) determined that outcomes improved when therapists were provided clientfocused feedback that alerted therapists to potential treatment failure with at-risk clients. Due to the influence of the managed care movement (Wampold, 2001), it appears that an increasing number of agency settings that employ MFTs will begin to rely on some kind of feedback mechanism. Educators and supervisors should prepare therapists-in-training for this eventuality—especially as there is evidence that this type of alliance feedback improves their therapy. While access to empirically validated alliance measures and accompanying feedback methodologies may not be feasible for every COAMFTE training program or practicing clinician, there are other viable and accessible alternatives that can be used to track the therapeutic relationship. As an example, Duncan and Miller (2008) have developed readily available measures of alliance and outcome that can be used to track therapeutic progress (www.scottdmiller.com). These measures are brief, and scoring is quick and easy, making them well-suited for clinical practice. This type of applied progress research (Pinsof & Wynne, 2000) can be valuable to research informed clinicians because it gives first hand insight into the alliance and other change processes of clients (Karam & Sprenkle, 2010). Suggested solution: Conduct an alliance feedback interview with the client system. Initiating alliance dialogue is a crucial (but often overlooked) skill in the training and development of a MFT. As therapists practice and become more comfortable giving and soliciting feedback on these alliance dimensions and talking to the entire system about their experience in therapy, they are gradually making the smooth transition between session content and the overall process of the therapy relationship. The alliance feedback interview assignment was designed specifically to develop further this skill, focusing on ways for the student to discuss the tasks, goals and bonds of therapy with a couple or family system. Some of the questions that students are required to ask include: (a) What has been the pivotal moment or most important part of this therapy for you thus far? (b) What about my therapeutic style or approach works well for you? (c) What have we done in this therapy that hasn’t worked as well for you? (d) If you feel misunderstood in this therapy or believe I have sided with another family member, how would you address it with me? After conducting the interview, students are instructed to reflect critically on their capability of soliciting feedback and how aspects of the experience will be integrated into their emerging clinical repertoire. Suggested solution: Incorporate empirically informed alliance instruments into your practice of MFT. For this assignment in an applied research course, students are instructed to implement an alliance feedback instrument on five or more occasions in their work with at least two of their cases, one of which should be a couple or family. Students are required to videotape both how they explain the purpose of the instrument to a client system and how they give and receive feedback using the alliance measure. Finally, students write a five-page critical reflection about using the instrument, addressing the following questions: (a) How did the alliance changed throughout treatment? (b) How did client responses either confirm or disconfirm your clinical impressions of the alliance? (c) How were you different as a therapist as you used the feedback forms? (d) What surprised you in using these forms? and (e) What are your recommendations for using this type of insession alliance feedback instrument based upon what you learned through this process? Threat #4: A Lack of Respect for MFT Models The scenario: A student stops paying attention in a theory class, contending that having a strong alliance is all one really needs to become a successful MFT because the therapeutic relationship, not a specific model, is primarily responsible for therapeutic change. As opposed to a radical stance on common factors (Duncan & Miller, 2000), which diminishes the value of models, a therapist with a moderate common factors stance sees merit in learning specific MFT theories and approaches. October 2015

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After all, common factors are not “islands,” but rather they work through models (Sprenkle & Blow, 2004b). Models provide a beginning family therapy student structure, organization, and coherence—a therapeutic blueprint to guide work with client systems. Only when we learn several models really well can we see the similarities that exist between them (Sprenkle et al., 2009). Suggested solution: Help students develop a mutual appreciation for both models and common factors. Do this by discussing the therapeutic alliance in terms of how it is embedded in other popular MFT approaches. That is, discuss the therapeutic alliance in terms of its role in all classic and current MFT models. Educators may do this in traditional theory courses or in clinical research classes (Karam & Sprenkle, 2010). They can emphasize that many MFT models use distinct wording when referring to therapeutic alliance. For example, structural family therapists refer to joining (Minuchin, 1974), and strategic family therapists refer to the social stage (Haley, 1976). Many current empirically supported, evidenced-based treatments like EFT (Johnson, 2004), Brief Strategic Family Therapy (Szapocznik & Kurtines, 1989), and Multidimensional Family Therapy (Liddle, 2002) also mold this construct into the steps of their respective models. Suggested solution: The Tower of Babel exercise. This assignment requires students to integrate knowledge from MFT coursework in conjunction with their own clinical experiences (Karam, Blow, Sprenkle, & Davis, 2014). Students are instructed to propose three different processes that they believe are integral to cultivating a strong therapeutic alliance in systemic therapies. Specifically for this assignment, they are instructed to: (a) Describe in detail these three alliance processes. There should be one process for each different dimension of the alliance, that is, tasks, goals, and bonds; (b) Describe techniques that target these processes using model-specific language from at least four different relational therapy models; and (c) Find MFT training video clips that illustrate therapists from at least two different modalities doing what was described in part a. For example, making clients feel comfortable, understood, and not judged is an essential process in building a therapeutic bond. In EFT, a therapist would facilitate this process by using the technique of empathic reflection (Johnson, 2004). In a Bowenian approach, a therapist would accomplish this by modeling a non-anxious presence (Bowen, 1976). A symbolic-experiential therapist would employ Whitaker’s concepts of humor and an authentic self to put the client system at ease (Whitaker & Bumberry, 1988). Finally, a structural family therapist parallels a family’s mood or behavior through the technique of mimesis to join and build the bond dimension of the therapeutic alliance (Minuchin, 1974). Threat #5: Lack of a Repair after the Tear The scenario: The student therapist is aware of a problem in the alliance but is unsure how to directly address the situation with the client system. Improperly managed therapeutic relationships in MFT may lead to a split alliance (Pinsof, 1995), in which the therapist has a strong alliance with one subsystem and a weak alliance with another subsystem of the client system. Typically, with split alliances, the viability of the therapy depends on whether the positive alliance is with a more powerful subsystem. A split alliance may quickly degenerate into an alliance rupture. The rupture and repair of the therapeutic alliance has been articulated both in theory and research. Bordin (1980) labeled this phenomenon as the “tear and repair” of the therapeutic alliance. Stiles et al. (2004) found that 22% of a sample in individual therapy displayed this rupture– repair pattern. When graphed, this relationship resembles the letter V because alliance starts high, drops drastically as a result of the rupture, and then returns to a healthy level after the therapist resolves the therapeutic impasse. Clients with this pattern had greater treatment gains than did other clients. This finding supports the belief that a successful tear and repair will strengthen the overall therapeutic alliance by allowing clients to explore safely their relational problems with the therapist in the here and now of the therapeutic relationship (Pinsof, 1995; Safran, 1993; Safran & Muran, 2000). The results of the more recent studies, in part, support Gelso and Carter’s (1994) belief that for some clients, the high alliance common to early treatment suffers a decline and then a subsequent return to the initial, or higher, level of positive alliance. While sometimes a rupture is immediately apparent to both client and therapist in the form of a frustrated or angry outburst, in other instances, this tear may be subtle, unspoken and unacknowledged within the session. Clients may not share negative feelings they hold toward their therapists or their therapy out of fear of offending/criticizing the therapist (Safran, Crocker, McMain, & Murray, 1990). 394

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Suggested solution: Practice alliance repair strategies. Safran and Muran (2000) suggest the following four steps to repair the therapeutic alliance after a rupture: (a) Encourage and validate client emotional reaction to the tear; (b) Show appreciation for client’s openness and ability to acknowledge the rupture; (c) Explore the impact and consequences of the rupture on the rest of the therapeutic and client system; and (d) Acknowledge therapist’s own role in creating the tear. Safran and Muran (1996) contend that if therapists are willing to accept criticism and take responsibility for their actions, then the sharing of negative client feelings can lead to an increased alliance and positive outcomes. These findings encourage therapists to both solicit and offer feedback on the therapeutic relationship. A logical place to begin training students on this repair process would be a pre-practicum or skill-building experiential course at the onset of the curriculum. As students practice dealing with hurt or hostile clients through simulated cases, they prepare for the real world of their first clinical placements. Suggested solution: Guard against triangulation in family subsystems to avoid split alliances. Although some types of ruptures (i.e. feeling ignored, judged, deceived) are inherent to every psychotherapy modality, MFT faculty and supervisors should prepare their students for specific relational ruptures that could only occur in a conjoint therapy setting. These types of alliance ruptures may emanate from spousal, co-parental, parent–child, sibling, or extended family therapeutic relationships. For example, a teenager is no longer willing to participate in family therapy after she discovers that her therapist shared with her mother that she secretly snuck out the house to attend a party in the interim between sessions. These faculty designed scenarios should also address imbalances in the alliance subsystems, replicating feelings of unfairness or injustice from a disgruntled spouse or family member. In the following transcript of couples therapy, the MFT is acknowledging a split alliance and actively trying to repair it by obtaining client “buy-in” on tasks and goals to improve bonds. Therapist: Based on what you’ve told me today, what I see on your therapy survey, and what I can observe in your tone and body language, I wondering if you’re unhappy with the current state of our couple’s therapy? Husband: Actually, yes. . .this therapy is terribly one-sided. It seems to me that my wife always feels like I don’t care and that I am the cause of all the problems in this relationship. I feel frustrated because you’re always taking her side. I don’t need to pay 100 bucks per hour to hear what I can get for free at home! Wife: I don’t agree! You shut down and never take accountability for what you do that contributes to our problems. Everybody is not always out to get you. Please, stop ignoring me all the time! Our therapist is only here to teach us skills about how to communicate better and “fight” fairly. Therapist (Addressing husbands concerns directly): Even though you’re clearly upset now, I’m glad you feel comfortable enough to raise this concern with both your wife and myself. It’s much better than you talk about these frustrations early on in our work before you completely throw in the towel. Husband: Although I care deeply about my marriage, you’re right, I’m really close to giving up on this therapy! Therapist (To Husband): I haven’t meant to intentionally, but in trying to understand better your wife’s point of view and validating her feelings today, I have made you feel like your contributions to our therapy have gone unnoticed. Although you feel frustrated now, I want to reiterate that I believe you have been working very hard in our sessions and that your continual contributions are integral to the future of this work. Before we go any further, let me reassure you that I do not “pick sides” — I am on the “side” of both you and your wife together as a couple. Husband: I feel like I have been working, too. I don’t purposely want to get defensive or shut down when she questions me. Even though I understand our “cycle” now, I’m still not confident that I have the skills to break it when push comes to shove at home.

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(Looking at wife for support) Right now, I really need you to trust that I want this to work, but I’m just not sure how to reassure you. Wife: I know. I don’t always want to feel like a “nag,” but this is the only way I know how to make you notice. Through our initial sessions, I’ve learned my role in our cycle and that my strategy clearly isn’t working either. Trust me, even if I don’t admit it all the time, I’m part of the problem too! Therapist: To me, it actually sounds like you both are more in agreement than you may have originally thought. Not only do you understand your individual contributions to the cycle you are in, but both of you also share the same goal for our work: you want to communicate without feeling so frustrated when you distance from each other. You both want to feel more connection and hope. Is that right? Wife: Of course. Husband: That’s all I’ve ever wanted! Therapist: It also seems that I may have not been clear enough in giving you feedback on your progress (both as a couple and individuals) and in talking about the structure of the future of our therapy. Now that you appreciate each other’s positive intent in our sessions, we can start to learn the skills to break the cycle you get into and learn how to communicate more effectively. This will include practicing new techniques to break the cycle both in-session with me and during the week outside of here as homework. Is that a plan that will work for you? Husband: Yes, I need to learn what to do differently when I feel frustrated and begin to shut down. Wife: Yes, I want to learn how to get him to really listen to me without the constant nagging. Threat #6: A Lack of Goal Specificity and Consensus The scenario: Although the student therapist understands the presenting problem, there is neither consensus nor specificity around the goals in the client system. To have a strong goals dimension of the therapeutic alliance, clients must experience the therapist as collaborating with them on the problems for which they are seeking help. Ideally, goals should originate from the client, and then be clarified or refined by the therapist. If therapists prematurely focus the therapy on what they deem important rather than addressing client concerns, the alliance may never solidify. There are risks involved in not clearly defining treatment goals at the onset of therapy (within the first 1–3 sessions). The ambiguity involved in not knowing exactly what you are working toward could lead to confusion and frustration, both from the client and the therapist perspective. These feelings may prevent engagement or lead to early drop-out (Davis & Piercy, 2007). Suggested solution: Develop goal statements. To avoid uncertainty and establish a benchmark for progress, therapists must lead clients in the discussion and subsequent operationalization of treatment goals. Some clients may easily be able to identify general areas of their relationship they want to work on in therapy (i.e. communication, trust, respect), but need assistance in refining therapy goals to move from the abstract to the concrete. Goals should be clear, specific, and measurable. The terms of the goal may be further refined by specifying what behavior will occur, how often it will happen, and under what conditions. The miracle question (deShazer, 1988) can be used to help clients visualize and articulate what their problems would be like if suddenly they were solved. A variant on this question to highlight potential goals is, “If I were to wave a magic wand and wave your problems away, what would you be doing?” It may also benefit clients to condense larger goals into smaller, more time-limited subgoals. By helping the client modify their goals in this way, the seemingly insurmountable outcome becomes more organized, manageable, and attainable. When working with multiple clients in the same system, therapeutic aims might be further divided into individual and family goals. In conjoint sessions, MFTs must avoid accepting only

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one member’s conceptualization of the problem, as couples or families do not always have the same motivations or goals. According to Friedlander et al. (2006), therapists must limit therapeutic ultimatums and the tendency for clients in relational therapies to define the outcome of a goal in “win/lose” terms. If there is disagreement within the client system on goals, MFTs should take an active and unifying stance in reframing the resistance by finding shared meaning and a sense of hope. Rather than a distinct phase of therapy that only occurs once and is never revisited, goal setting should be part of an ongoing dialogue between client system and therapist—one that is frequently addressed and modified if necessary throughout the course of treatment. During this dialogue, therapists should explore with clients’ potential constraints to achieving these goals. To develop competency within this dimension of the alliance for each of their relational cases, students present a one-page goal statement to both their supervisor and clients for signed approval. Signing the document increases accountability for both the client system and the student, keeping the goal at the forefront of the therapy. Each goal is written down and contextualized by answering the following modifier questions: (a) Which member of the system set each goal? (b) Is it a couple/ family or individual-level goal? (c) How and when will the goal be measured?; (d) How did the therapist modify or reframe the goal to promote system-wide support?; (e) What additional factors could keep the system from achieving their goals?; and (f) On a 1–10 scale, how confident is everyone in the system that they will achieve the goal? For example, a wife is pursuing couples therapy because she wants her husband to communicate and share more vulnerable emotions with her. She will measure progress on this goal by the number of times he approaches her in the evenings to vent about his work frustrations after their two small children go to bed. The husband, on the other hand, only wants to participate in the therapy if it will improve his sex life. He states that his individual goal is to make love to his wife 2– 3 times per week. To achieve consensus amidst such different surface motivations, the MFT must skillfully reframe these individual goals to address the underlying needs for connection of both partners. In this instance, the therapist clarifies that the couple goal is to increase intimacy in the marriage. By framing the goal within the broader context of intimacy, the therapist connects with the wife around her need for emotional closeness without ignoring the husband’s concern for increased physical connection in the marriage. When thinking of constraints that could prevent them from reaching this goal, both agree that having young children reduces the ability to spend as much quality time together currently as they did when they were first married, and this underlines another goal: finding or making quality time for each other. By using a scaling question, the therapist learns that the husband (9) and the wife at (7) are both hopeful about the future. Threat #7: Lack of Clarity around Homework and Other Therapeutic Tasks The scenario: Even though the student therapist is very passionate about the new model he learned in class and is committed to helping his clients by using some new therapeutic techniques, both husband and wife look confused and lost when he attempts to explain the homework and what will be in store for future sessions. The tasks dimension of the therapeutic alliance refers to the degree that clients find both the structure and activities of therapy helpful and consistent with their expectations (Bordin, 1979). Whereas clients should take the lead in initiating goals, it is often the therapist’s responsibility to develop appropriate tasks. For those clients who enter treatment lacking some type of order in their personal lives or without previous therapy experience, the structure provided by a therapist may be a stabilizing influence. Therapists must be careful to match appropriate tasks with the proper developmental and cognitive level of the client. In devising appropriate therapeutic tasks, however, the therapist should not only use clinical wisdom, but must also pay close attention to client system values, preferences, ethnicity and culture to ensure goodness-of-fit (Sprenkle et al., 2009). For instance, if a couple enters therapy expecting to learn fair-fighting skills with an action-oriented approach, but the therapist devises a structure that is more self-reflective and insight-oriented, then the overall fit and agreement on this tasks dimension will probably be very low (Beutler, Harwood, Alimohamed, & Malik, 2002). Johnson and Talitman (1997) reported that this tasks component was the most important alliance dimension in predicting a successful response to EFT. Suggested solution: Explicitly link therapeutic tasks, including assigned homework, to previously articulated therapy goals. In order to promote healthy bonds, therapeutic tasks should be explicOctober 2015

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itly linked to treatment goals. In a qualitative inquiry, Sells, Smith, and Moon (1996) reported that treatment effectiveness for both therapists and clients was linked to the perceived clarity of goals and their relationship to therapeutic tasks. Bordin (1979) believed it was the synergy between goals and tasks that gave rise to strong emotional bonds. Therapists should not take it for granted that clients automatically understand why they are being asked to practice a skill or complete a homework assignment. Engagement may be threatened if a therapist does not make his or her rationale transparent, and if the clients do not “buy” his or her rationale (Davis & Piercy, 2007). Threat #8: Lack of Support from the Indirect System The scenario: The student therapist fails to attend to important relationships outside of the room in individual therapy that may negatively impact the outcome of the treatment. Many marriage and family therapists, although trained to work with multiple people at the same time, may have a significant number of individual clients in their caseload. In a national survey, Doherty and Simmons (1996) reported that one-half of the clients treated by MFTs were seen in individual sessions. The trend continues, as a more recent sample by Northey (2002) detailed MFTs seeing clients individually 54% of the time. Even while working with individuals, MFTs view their clients through a relational and contextual lens. Client systems include key members that may participate in maintaining or resolving the presenting problem. In individual therapy, many times, these key members are not present in the room. While they are important to the treatment, they reside in the indirect system (Pinsof, 1995). When building an alliance in individual therapy, the therapist must remember that they are intervening into a system that is larger than the people with whom they are interacting directly. Even if the client is motivated and fully engaged in therapy, members of the indirect system who do not either adequately understand or believe in the treatment may negate therapeutic gains and momentum. Consequently, an individual client may need family and friends to support the task, goals, and bonds of therapy in order to succeed. Suggested solution: Actively explore and monitor the impact of the indirect system in individual therapy. A therapist may be able to monitor the client’s alliance with the indirect system by asking some of the following questions: (a) How does your relationship with important people outside of this therapy room affect your progress in therapy? (b) Do you feel that I as the therapist appreciate how important some of your relationships are to you? (c) What would the people who are important to you think about the way your therapy is being conducted? (d) Do you feel that the people who are important to you would trust that this therapy is good for your relationships with them? and (e) How do you feel about what important people in your life think about your therapy? If the therapist feels like therapeutic progress is being jeopardized by involvement from someone in the indirect system after this assessment, he or she could either engage in boundary making work with that client or intentionally reach out to the negative person, in essence moving the client from the indirect into the direct system to address the conflict.

CONCLUSION While some pure model enthusiasts have labeled general treatment components, like the therapeutic alliance, as too broad or abstract to be operationalized into teachable constructs, this article serves as another important progression in the refinement and teaching of MFT common factors. We have highlighted the unique aspects of the therapeutic alliance as related to the practice of MFT, as well as provided possible solutions to alliance threats commonly experienced by student therapists. Although we have developed these ways of teaching the alliance in master’s level programs, the ideas and examples outlined above are meant to be illustrative, not exhaustive. There are surely many other effective strategies not documented, and thus we strongly encourage any future dialogue that keeps the emphasis on the therapeutic alliance at the forefront of the art and science of MFT training.

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