Pressure to Attend Therapy, Dyadic Adjustment, and Adverse Childhood Experiences: Direct and Indirect Effects on the Therapeutic Alliance in Couples Therapy

Abstract

In this study we examine the role that pressure to attend therapy, dyadic adjustment, and adverse childhood experiences (ACEs) play in developing the therapeutic alliance. A total of 351 couples received treatment as usual at three family therapy training clinics. Participants rated predictor variables at intake and alliance at the fourth session. Results of a path analysis indicate that each partner's dyadic adjustment is directly associated with the quality of her or his own alliance. In addition, when male partners report more ACEs and pressure to attend treatment, their own alliance scores decrease. Additionally, when one partner reports feeling pressure to attend therapy, the other partner's alliance decreases. Finally, for males, there is an indirect effect of dyadic adjustment on alliance through pressure to attend therapy. These results suggest that clinicians should routinely assess relationship adjustment, how pressured each partner is feeling to attend treatment, and ACEs; as these may impact alliance quality. BACKGROUND AND SIGNIFICANCEThe therapeutic alliance is one of the most robust predictors of therapeutic outcomes across individual, couple, and family therapy (Barber et al., 2001;Friedlander, Escudero, Heatherington, & Diamond, 2011). A recent meta-analysis of the alliance-outcome link in couple and family therapy provides strong evidence for this relationship, with a medium effect size (d = 0.6; Friedlander, Escudero,Welmers-van de Poll, & Heatherington, 2018). Despite the importance of the alliance to successful therapeutic outcomes, we know surprisingly little about factors that predict successful alliance formation with couples. As a result of this knowledge gap, clinicians who hope to improve outcomes by improving the alliance have little guidance regarding how to do so, what elements of a client's individual history to pay attention to, or what elements of the client's relationship to address.

Treated together–changed together: The application of dyadic analyses to understand the reciprocal nature of alliances and couple satisfaction over time

“…Even though we acknowledge that the uniqueness of the treatment program that is on offer at the FU might limit the generalizability of the results, we propose that the patterns of associations of alliances and couple relationship satisfaction identified would likely be similar in other contexts of treatment (e.g., outpatient). Studies from other contexts on the alliance in couple therapy show similar results as our study, hence supporting such an interpretation (e.g., Anderson et al, 2020 ; Halford et al, 2016 ). Lastly, the naturalistic design of this study may also limit generalizability because several indirect effects are not accounted for (e.g., what interventions were implemented by the couple therapist?).…”

“…Further, evidence also suggests that men often are the ones that experience pressure to attend therapy, which initially may challenge alliance formation with their therapist (Halford et al, 2016 ). However, recent research has also implicated previous trauma as a variable that negatively influences men's alliance at the beginning of therapy (Anderson et al, 2020 ).…”

“…We mention this since most of the sample do fulfill the criteria for a psychiatric diagnosis according to the ICD‐10 (World Health Organization, 1992 ) and at least half of the sample has been exposed to a traumatic experience. From the literature, we know that there is a negative association between mental distress and couple satisfaction (Whisman & Baucom, 2012 ; Whisman et al, 2000 ), as well as a suggested link between trauma and alliance formation in couple therapy (Anderson et al, 2020 ). We are thus cautious in generalizing our findings to other populations.…”

“…Anderson and Johnson ( 2010 ) seminal paper on therapeutic alliances was most likely the first scientific publication to introduce the APIM to the field of couple therapy. A common drawback of the studies conducted (e.g., Anderson & Johnson, 2010 ; Anderson et al, 2020 ; Bergeron et al, 2020 )—is that they include a limited set of assessment points. Essentially, this means they reveal reciprocal influences, but not across time.…”

Couple Satisfaction, Depressive Symptoms, and the Therapeutic Alliance: A Systemic Perspective

“…Male clients’ alliance with the therapist appeared to exert a bigger influence on treatment success compared to female clients (Anker et al, 2010; Glebova et al, 2011). Contrastingly, Anderson and colleagues (2020) found little evidence that the effect of relationship quality on alliance differed by gender. We contend that such inconsistencies in the extant literature may be due in part to the focus on the direct effect of the couple therapeutic alliance on treatment outcomes, without considering the dyadic interaction effects among alliance, depressive symptoms, and couple satisfaction of both partners.…”