Traditional Intervention Strategies
The case study for this chapter will illustrate in detail one way to conduct family therapy. Besides the strategies presented in the case study, there are two additional points on family therapy applications to which the reader's attention is directed. The first is an understanding of the significance of nonspecific factors in family therapy outcomes. The second is how to structure the first session so that family therapy can get off to a good start.
Specific Versus Nonspecific Factors
A strong current trend in individual-focused counseling or therapy research is an examination of the specific and nonspecific factors involved in treatment outcomes. Specific factors are those counseling or therapy activities that are specific to a particular approach, for example, a strategic family therapist's use of a "proscribing the symptom" intervention. Nonspecific factors are those change-producing elements present in counseling or therapy regardless of theoretical orientation. Many nonspecific factors have been proposed, but few have withstood empirical testing. One exception is working alliance. In fact, working alliance scores are the best-known predictor of counseling or therapy outcomes (Horvath, 1994).
The modern transtheoretical definition of working alliance was promulgated by Bordin (1994), who posited that there are three components of working alliance: task, goal, and bond. He conceptualized these three components as follows:
1. Task refers to the in-therapy activities that form the substance of the therapeutic process. In a well-functioning relationship, both parties must perceive these tasks as relevant and effective. Furthermore, each must accept the responsibility to perform these acts.
2. Goal refers to the counselor or therapist and the client mutually endorsing and valuing the aims (outcomes) that are the target of the intervention.
3. Bond embraces the complex network of positive personal attachments between client and counselor or therapist, including issues such as mutual trust, acceptance, and confidence. (Adapted from Horvath, 1994)
Overall, Bordin's working alliance model emphasizes "the role of the client's collaboration with the therapist against the common foe of the client's pain and self-defeating behavior" (Horvath, 1994, p. 110).
Family therapists have been slower to examine the nonspecific factors involved in positive treatment outcomes (Blow, Sprenkle, & Davis, 2007). One exception was William Pinsof of the Family Institute (Evanston, Illinois). In his research, Pinsof (1994) found a positive relationship between working alliance and family therapy outcomes. The few other studies conducted on working alliance in family therapy produced similar results (Knobloch- Fedders, Pinsof, & Mann, 2004).
Given the effectiveness of working alliance concerning treatment outcomes, practitioners of family therapy would be wise to attend carefully to such alliances. However, such attention would run counter to the preeminence family therapists give to technique. Coady (1992) noted that the emphasis in family systems theory on homeostasis has led to family therapists' viewing family members as being dominated by the family system. He stated that family therapists "often expect families to exert an oppositional force against change efforts, and they feel compelled to manipulate the family into change" (p. 471). Unfortunately, such a perspective runs exactly counter to formation of strong working alliances. I want to be careful to note that a commitment to build strong working alliances with clients' families does not mean counselors have to dismiss technique. Rather, it means acknowledging that techniques should not be separated from the interpersonal and cultural contexts in which they occur (Coady, 1992).
In their study on the development of working alliance in couples therapy, Thomas, Werner-Wilson, and Murphy (2005) found gender differences in alliance development. Thomas and her colleagues found that for men, negative statements made by their partner were a consistent negative predictor of working alliance. They went on to note that their results "indicate that men expect therapists to provide a refuge from what they see as a barrage of negative statements from their partners. Therapist who fail to provide this protection for men effectively contribute to the lack of therapeutic alliance" (p. 31). It is interesting that Thomas et al. did not find that negative statements made by a partner influenced working alliance for women clients. In reference to both genders, Thomas et al. (2005) found that "partner self-disclosure positively influence the bond dimension of alliance for both men and women. When the therapist actively creates a safe place for partners to disclose their thoughts and feelings, clients feel more bonded to their therapist" (p. 33).
The Family Interview
From the start, Haley (1991) advocated brevity and clarity in counseling or therapy work with families. He stated, "if therapy is to end properly, it must begin properly – by negotiating a solvable problem and discovering the social situation that makes the problem necessary" (p. 8). To help family therapists start on a good note, Haley outlined a structured family interview for use during an initial session. The five stages of this structured family interview are as follows:
1. Social: The interviewer greets the family and helps family members feel comfortable.
2. Problem: The interviewer invites each person present to define the problem.
3. Interaction: The interviewer directs all members present to talk together about the problem while the interviewer watches and listens.
4. Goal setting: Family members are invited to speak about what changes everyone, including the "problem" person, wants from the therapy.
5. Ending: Directives (if any) are given and the next appointment is scheduled.
The information gained from the first interview helps the family therapist form hypotheses about the function of the problem within its relational context. Moreover, this information can help the family therapist generate directives to influence change. For Haley (1991), "the first obligation of a therapist is to change the presenting problem offered. If that is not accomplished, the therapy is a failure" (p. 135).
The Evolution of Family Therapy
No subfield in counseling can stand still and remain relevant. Family therapy is no exception. In the past decade there have been a number of factors that have spurred innovation in family therapy. These factors include (a) the changing demographics of the nation, (b) the drive for greater health care cost containment, (c) increased knowledge concerning the "active ingredients" of counseling interventions, and (d) innovation in counseling research techniques. The end result of these factors has been the brief manualized versions of integrative family therapy. Before these versions are discussed, the descriptor integrative needs definition. There exist a number of high-quality psychotherapy outcome studies that have pitted different approaches against each other (e.g., the National Institute of Mental Health's Comparative Depression Study, the National Institute on Alcohol Abuse and Alcoholism's Project Match). A consistent finding of these studies is that manualized versions of different psychotherapeutic approaches produce equivalent results. Thus, psychotherapy research and practice have transitioned from a competitive era to an integrative era (Nuttall, 2008).
In family therapy, prominent theorists have developed and manualized integrated family therapy models. These models include Howard Liddle's multidimensional family therapy, Jose Szapocznik's brief strategic family therapy (BSFT), William Pinsof's integrative problem-centered therapy, and Nathan Epstein's McMaster family therapy. All have been researched extensively. Szapocznik's manualized integration of systemic and structural modalities may be the most important going forward given the extensive efficacy research done on this approach with clients of color.