|
MANUALES BÁSICOS Corbella, S., y Botella, L. (2004). Investigación en psicoterapia:Proceso, resultado y factores comunes. Madrid: VisionNet. Friedlander, M., Escudero, V., y Heatherington, L (2009). La alianza terapéutica. Barcelona: Paidós. ARTÍCULOS SELECCIONADOS Escudero, V. (2012) Reconsidering the ‘heresy’ of using treatment manuals. Journal of Family Therapy, 34:106-113. Some argue that the medical model and the experimental design that underlies the use of treatment manuals to prove the efficacy of a psychotherapeutic treatment clashes with the theoretical basis of family therapy. From the point of view of the empirically supported treatments (ESTs) movement, treatment manuals are the operationalization of the independent variable in a clinical trial; the therapist is only part of the procedure and the therapeutic relationship is a confounding variable. Applying that logic to the practice of family therapy might be considered a heresy. This article argues that paradoxically, this heresy has a lot to offer the practice of family therapy. Research is the best way to answer questions like ‘how does family therapy work?’ ‘What makes ‘good therapy’ good?’ ‘Do therapists do what they say they do'? This article recommends an alternative framework for integrating ESTs into practice by proposing empirically informed guides to practice which, being less formulaic, encourage process-outcome research, are coherent with the systemic model and do not constrain the therapist's creativity. Such guidelines allow therapists to use manuals flexibly so that they deepen the understanding of the process of therapy. Higham,J.E., Friedlander, M.L., Escudero, V. & Diamond, G. (2012) Engaging reluctant adolescents in family therapy: an exploratory study of in-session processes of change. Journal of Family Therapy, 34:24-52 Informed by a trans-theoretical model of the therapeutic alliance in conjoint family therapy, this exploratory study was the initial stage in a task analysis of critical shifts in adolescent engagement. Specifically, we compared sessions in which a resistant adolescent either did or did not shift from negative to positive engagement during the session. Two successful and two unsuccessful change events were selected from an archival data set based on SOFTA ratings of the therapeutic alliance. The results suggested that one parent element (support) and five therapist elements (structuring therapeutic conversations, fostering autonomy, building systemic awareness, rolling with resistance and understanding the adolescent’s subjective experience) seemed critical for successfully facilitating adolescent engagement. The qualitative results were informed by the adolescent’s self-reported target complaints pretreatment, which suggested varying reasons for the teenagers’ active or passive disengagement. Implications for practice and recommendations for future research are offered to continue this line of inquiry. Escudero, V. Boogmans, E., Loots, G., & Friedlander, M.L. (2012) Alliance Rupture and Repair in Conjoint Family Therapy: An Exploratory Study. Psychotherapy, 49:26-37. In this article, we introduce a methodology for studying alliance rupture and repair in conjoint family therapy. Using the System for Observing Family Therapy Alliances (Friedlander, Escudero, & Heatherington, 2006), we identified rupture markers and repair interventions in a session with a single mother and her 16-year-old “rebellious” daughter. The session was selected for analysis because a severe rupture was clinically evident; however, by the end of the session, there was an emotional turnaround, which was sustained in the following session and continued until the successful, mutually agreed upon termination. The first rupture occurred when the psychotherapist suggested that the mother explore, in an individual session, how her “personal stress” may be affecting her daughter. The observational analysis showed repeated rupture markers, that is, confrontation and withdrawal behavior, hostile within-family interactions, and a seriously “split” alliance in family members’ expressed feelings toward the psychotherapist. The time-stamped behavioral stream showed that the psychotherapist focused first on safety, then on enhancing his emotional connection with each client, and finally on helping mother and daughter understand each other’s behavior and recognize their shared isolation. de la Peña, C. M., Friedlander, M. L., Escudero, V., & Heatherington, L. (2012). How Do Therapists Ally With Adolescents in Family Therapy? An Examination of Relational Control Communication in Early Sessions. Journal of Counseling Psychology, 59:339-351. Sequential analyses examined associations between the working alliance and therapist–adolescent communication patterns in 10 Spanish cases of brief conjoint family therapy. Early sessions with strong versus problematic alliances, rated by observers, were selected for coding of relational control communication patterns. No differences were found in the frequency of exchanges, but competitive responding by the therapists (reflecting an interpersonal struggle for control) was significantly more likely in problematic alliance sessions than in strong alliance sessions. Cases in which the adolescent’s alliance with the therapist remained positive from Session 1 as compared with Session 3 showed a decrease in the likelihood of competitive symmetry. Notably, when the quality of the alliance deteriorated over time, the therapists were increasingly more likely to respond to the adolescents’ domineering messages in a competitive manner. Results underscore the need to avoid competitive responding in order to ally with adolescents in conjoint family treatment. Escudero, V., Friedlander, M. L., & Heatherington, L. (2011). Using the e-SOFTA for video training and research on alliance-related behavior. Psychotherapy, 48, 138-147. In this article, we describe a specific technology for training/supervision and research on the working alliance in either individual or couple/family therapy. The technology is based on the System for Observing Family Therapy Alliances (SOFTA; Friedlander, Escudero, & Heatherington, 2006), which contains four conceptual dimensions (Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family), observational rating tools (SOFTA-o), and self-report measures (SOFTA-s) shown to be important indicators of therapeutic progress. The technology, e-SOFTA, is a computer program (available for PC downloading free of charge) that can be used to rate client(s) and therapist on the specific SOFTA-o behaviors that contribute to or detract from a strong working alliance in each dimension. In addition to providing time-stamped frequencies of alliance-related behaviors, e-SOFTA allows users to link the observed behaviors to qualitative comments and to compare one person’s rating of a session to that of another person. Suggestions are provided for using e-SOFTA in research, in didactic training, and in supervision, including a specific training module for introducing graduate students to the working alliance and assessing their observational and executive skills. Friedlander, M. L., Escudero, V., Heatherington, L., Diamond, G. M. (2011) Alliance in couple and family therapy, Psychotherapy, Vol 48(1), 25-33. Couple and family therapy (CFT) is challenging because multiple interacting working alliances develop simultaneously and are heavily influenced by preexisting family dynamics. An original meta-analysis of 24 published CFT alliance-retention/outcome studies (k = 17 family and 7 couple studies; N = 1,416 clients) showed a weighted aggregate r = .26, z = 8.13 ( p < .005); 95% CI = .33, .20. This small-to-medium effect size is almost identical to that reported for individual adult psychotherapy (Horvath Del Re, Flückiger, & Symonds, this issue, pp. 9 –16). Analysis of the 17 family studies (n = 1,081 clients) showed a similar average weighted effect size (r = .24; z = 6.55, p < .005; 95% CI = .30, .16), whereas the analysis of the 7 couple therapy studies (n = 335 clients) indicated r = .37; z = 6.16, p< .005; 95% CI = .48, .25. Tests of the null hypothesis of homogeneity suggested unexplained variability in the alliance-outcome association in both treatment formats. In this article we also summarize the most widely used alliance measures used in CFT research, provide an extended clinical example, and describe patient contributions to the developing alliance. Although few moderator or mediator studies have been conducted, the literature points to three important alliance-related phenomena in CFT: the frequency of “split” or “unbalanced” alliances, the importance of ensuring safety, and the need to foster a strong within-family sense of purpose about the purpose, goals, and value of conjoint treatment. We conclude with a series of therapeutic practices predicated on the research evidence. Escudero, V., Heatherington, L. & Friedlander, M.L. (2010). Therapeutic Alliances and Alliance Building in Family Therapy. In Muran, C. & Barber, J. (Eds.),The therapeutic alliance: An evidence-based approach to practice and training (pp.. 240-262). NY: Guilford. This chapter reviews the conceptualization, measurements, research, and clinical applications of the Therapeutic Alliance in Family Therapy. It is a complete and up-dated review of the therapeutic alliance in the context of systemic therapies. Muñiz de la Peña, C., Friedlander, M. L., & Escudero, V. (2009). Frequency, severity, and evolution of split family alliances: How observable are they? Psychotherapy Research, 19, 133-142. “Split alliances” (within-family differences in the emotional bond with the therapist) were studied in 19 U.S. and 21 Spanish families using the System for Observing Family Therapy Alliances (SOFTA; Friedlander, Escudero, & Heatherington, 2006). Examining individual family members’ scores on the corresponding self-report and observational Emotional Connection with the Therapist SOFTA scales, we identified mild, moderate, and severe split alliances. In both samples, self-reported splits occurred frequently and with almost all of the therapists. Although clients’ observed interactions with the therapist often mirrored their self reports, family members’ perceptions of the therapeutic bond were generally more discrepant than their behavior suggested. The majority of families that dropped out had a moderately or severely split alliance in at least one session. Escudero, V., Friedlander, M. L., Varela, N., & Abascal, A. (2008). Observing the therapeutic alliance in family therapy: Associations with participants’ perceptions and therapeutic outcomes. Journal of Family Therapy, 30, 194-204. Positive and negative alliance-related behaviours of 37 families seen in brief family therapy were rated from videotapes using the System for Observing Family Therapy Alliances (Friedlander et al., 2006b). Positive associations were found between in-session behaviour and participants’ perceptions of the alliance and improvement-so-far both early (session 3) and later in therapy (session 6). Binary logistic regression showed that successful outcomes (defined as consensus by therapist and all family members on general improvement and reduced problem severity) were significantly predicted by positive individual behaviour (Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System) in session 3 and productive within-family collaboration (Shared Sense of Purpose within the Family) in session 6. Shared Sense of Purpose was the alliance indicator most consistently associated with clients' and therapists’ perceptions of therapeutic progress; moreover, it was the only alliance indicator to improve significantly over time in treatment. Carpenter, J., Escudero, V., & Rivett, M. (2008). Training family therapy students in conceptual and observation skills relating to the therapeutic alliance: An evaluation. Journal of Family Therapy, 30, 411-421. This paper describes a training intervention to develop students’ conceptual and observation skills relating to the therapeutic alliance (TA) in family therapy. An evaluation methodology was developed and piloted.The knowledge and observation skills of family therapy students pre- and post-training were assessed in comparison to a non-intervention group of experienced clinicians. Students’ mean scores on the knowledge measure improved significantly from 43 % to 74 % (p =.001) and on the observation test from 43 per cent to 65 per cent, although this failed to reach statistical significance. There were no significant changes in the clinicians’ scores over the same period. The clinicians’ knowledge was higher initially, but the students had caught up after six months. In conclusion, training students in conceptual and observational skills relating to the therapeutic alliance may have a measurable effect. A “stepwise” methodology for demonstrating the relationship between training in TA and outcomes for families is proposed. Friedlander, M. L., Lambert, J. E., Escudero, V., & Cragun, C. (2008). How do therapists enhance family alliances? Sequential analyses of therapist ? client behavior in two contrasting cases. Psychotherapy: Theory, Research, Practice, Training, 45, 75-87. To identify alliance-related behavior patterns in more and less successful family therapy, we intensively analyzed two cases with highly discrepant outcomes. Both families were seen by the same experienced clinician. Results showed that participants’ perceptions of the alliance, session impact, and improvement at three points in time were congruent with the families’ differential outcomes and with observer-rated alliance behavior using the System for Observing Family Therapy Alliances (Friedlander et al., 2006a). In this measure, therapist behaviors contribute to the alliance and client behaviors reveal the strength of the alliance on four dimensions: Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family. In the poor outcome case, observer ratings and self-reported alliance scores revealed a persistently “split” alliance between family members; this family dropped out mid-treatment. Only in the good outcome case did the clients follow the therapist’s alliance-building interventions with positive alliance behaviors; sequential analyses showed that therapist contributions to Engagement significantly activated client Engagement behavior, and therapist Emotional Connection interventions significantly activated client Emotional Connection. Friedlander, M. L., Escudero, V., & Heatherington, L. (2006). Therapeutic alliances with couples and families: An empirically-informed guide to practice. Washington, DC: American Psychological Association. This book introduces our transtheoretical model of the therapeutic alliance in conjoint therapy, the System for Observing Family Therapy Alliances, or SOFTA. As a model, the SOFTA is an elaboration of our ongoing empirical work to develop and validate a set of tools, observational (SOFTA-o) and self-report (SOFTA-s), for estimating the strength of the alliance in couple and family therapy (CFT). In this book, SOFTA serves as an organizing framework for integrating extant theory, research and practice on the therapeutic alliance in CFT. We created the SOFTA to organize and synthesize the wealth of behavioral information that therapists should pay attention to in creating, nurturing, and sustaining alliances with family members who may be in conflict with one another or have highly variable motivations for treatment. Using the SOFTA, either the rating tool or informally, as simply as a framework for thinking about CFT processes, therapists (and supervisors) can evaluate the strength of alliances with different family members, identify problematic behaviors that threaten the alliance, and figure out how to move the therapeutic process forward. Beck, M., Friedlander, M. L., & Escudero, V. (2006). Three perspectives on clients’ experiences of the therapeutic alliance: A discovery-oriented investigation. Journal of Marital and Family Therapy, 32, 355-368. To deepen our understanding of the therapeutic alliance in conjoint treatment, we interviewed clients in four families about their individual, private experience of the alliance after an early session. These qualitative data were triangulated with family members’ scores on Pinsof’s (1999) Family Therapy Alliance Scale-Revised and observational ratings of their behavior on the System for Observing Family Therapy Alliances (Friedlander, Escudero, & Heatherington, 2006). This discovery-oriented investigation focused on three interrelated aspects of the alliance: the family’s shared sense of purpose about the needs, goals, and value of therapy (i.e., within-system alliance), split alliances with the therapist, and felt sense of safety within the therapeutic context. Results were highly consistent across the three perspectives and congruent with idiographic therapist-rated outcomes.
|
|
Asay, T.P., &
Lambert, M.J. (1999). The empirical case
for the common factors in therapy: Quantitative findings. In M.A.
Hubble, B.L.Duncan, & S.D. Miller (Eds.), The heart and soul of change:
What works in therapy (pp. 33-56).
Washington, DC: American Psychological Association. Beck, M.,
Friedlander, M. L., & Escudero, V. (2006). Three perspectives of clients’ experiences of the therapeutic alliance: A
discovery-oriented investigation. Journal of Marital and Family
Therapy, 32, 355-368. Carpenter,
J. Escudero, V., & Rivett, M (2008). Training
family therapy students in conceptual and observation skills relating to the
therapeutic alliance: an evaluation. Journal
of Family Therapy, 30: 411–424 Castonguay, L. G.,
Constantino, M. J., & Holtforth, M. G. (2006). The working alliance: Where are we and where
should we go? Psychotherapy: Theory, Research, Practice, Training, 43, 271-279. Escudero,V. y Friedlander, M. (2017) Therapeutic Alliance with Families. Empowering Clients in Challenging Cases. NY: Springer. Escudero, V., M. L.
Friedlander, Varela, N., & Abascal, A. (2008). Observing the
therapeutic alliance in family therapy:associations with participants’
perceptions and therapeutic outcomes. Journal of Family Therapy, 30: 194–214 Escudero, V., Heatherington,
L., & Friedlander, M. (in press) Therapeutic Alliances and Alliance
Building in Family Therapy. En Muran, C. &
Barber, J. (Eds.) The therapeutic alliance: An
evidence-based approach to practice and training. NY: Guilford. Friedlander, M. L.,
Escudero, V., Horvath, S., Heatherington, L., Cabero, A., &
Martens, M. (2006). System for Observing Family Therapy Alliances: A tool for research and practice. Journal of Counseling
Psychology, 53:214-225 Friedlander, M. L.,
Lambert, J., Escudero, V; Cragun, C. (2008). How do therapists enhance
family alliances? Sequential analyses of therapist-client
behavior in two contrasting cases. Psychotherapy:
Theory, Research, Practice, Training. 45:75-87. Heatherington, L., Friedlander, M. L., & Greenberg, L. S. (2005). Change process research in couples and family therapy: Methodological challenges and opportunities. Journal of Family Psychology, 19, 18-27. Maione, P.V., &
Chenail, R.J. (1999), Qualitative Inquiry
in Psychotherapy: Research on the Common Factors. In M.A. Hubble,
B.L.Duncan, & S.D. Miller (Eds.), The heart and soul of change: What
works in therapy (pp. 33-56).
Washington, DC: American Psychological Association. Muñiz de la Peña, C.,
Friedlander, M.L., & Escudero, V. (2009). Frequency, severity, and
evolution of split family alliances: How observable are they?. Psychotherapy
Research, 19:133-142. Sprenkle, D.H. &
Blow, A.J. (2004). Common factors and
our sacred models. Journal of Marital and Family Therapy, 30, 113-129. |