Journal of Marital and Family Therapy

doi: 10.1111/jmft.12113
October 2015, Vol. 41, No. 4, 415–427

THERAPEUTIC ALLIANCE AND RETENTION IN BRIEF

STRATEGIC FAMILY THERAPY: A MIXED-METHODS
STUDY
Alyson H. Sheehan, and Myrna L. Friedlander
University at Albany/SUNY

We explored how the therapeutic alliance contributed to retention in Brief Strategic Family
Therapy by analyzing videotapes of eight-first sessions in which four therapists worked with
one family that stayed in treatment and one family that dropped out. Although behavioral
exchange patterns between clients and therapists did not differ by retention status, positive
therapist alliance-related behavior followed negative client alliance behavior somewhat more
frequently in the retained cases. In the qualitative aspect of the study, four family therapy
experts each viewed two randomly assigned sessions and commented on their quality without
knowing the families’ retention status. A qualitative analysis of the audiotaped commentaries
revealed 18 alliance-related themes that were more characteristic of either the retained or
the nonretained cases.

In recent years, researchers have increasingly turned their attention to effectiveness trials that
assess, in community settings, the success of manualized treatments that have withstood the scru-
tiny of controlled clinical trials. The effectiveness of any theory-based treatment model, however,
depends not only on adherence, but also on the quality of important nonspecific therapeutic pro-
cesses, most notably the working alliance. Indeed, the alliance has been cited as the most critically
important aspect of change, more critical to outcome than the unique aspects of any specific theo-
retical approach (Fife, Whiting, Bradford, & Davis, 2014). A recent meta-analysis on the relation
of alliance to outcome in couple and family therapy (CFT; Friedlander, Escudero, Heatherington,
& Diamond, 2011) produced an average weighted effect size of .26, comparable to the effect size
reported by Horvath, Del Re, Fl€ uckiger, and Symonds (2011) for individual psychotherapy.
In Friedlander, Escudero, and Heatherington’s (2006) conceptual model of the working alli-
ance in CFT, the System for Observing Family Therapy Alliances (SOFTA), Bordin’s (1979) clas-
sic alliance conceptualization is captured in two dimensions, Engagement in the Therapeutic
Process (ENGAGE) and Emotional Connection to the Therapist (CONNECT), whereas the two
other SOFTA dimensions reflect unique characteristics of the conjoint modality: Safety within the
Therapeutic System (SAFETY) and Shared Sense of Purpose within the Family (PURPOSE).
SAFETY refers to an individual’s degree of comfort interacting and taking risks in a therapeutic
context with family members, whereas PURPOSE refers to the degree of within-family collabora-
tion and their valuing of conjoint therapy for addressing family concerns.
With few exceptions, most previous SOFTA studies have been conducted in the context of
nonmanualized “treatment as usual.” In the present mixed-methods study, we used the observa-
tional SOFTA system along with a qualitative analysis to investigate the relation of alliance in first
sessions to retention in Robbins, Feaster, Horigian, Rohrbaugh et al.’s (2011) multisite effective-
ness trial of Brief Strategic Family Therapy (BSFT). The importance of alliance building in first

Alyson H. Sheehan, Ph.D., and Myrna L. Friedlander, Ph.D., Educational and Counseling Psychology,
University at Albany/SUNY.
This research, conducted as a dissertation by the first author under the direction of the second author, was pre-
sented in October 2013 at the conference of the North American Society for Psychotherapy Research in Memphis,
TN. We are grateful to the other committee members, Laurie Heatherington and Alex Pieterse, to all of the coders,
and to Michael Robbins, Michael Rohrbach, Varda Shoham, and Jose Szapocznik for the use of their videotaped
data and for their consultation on the design of this study and their comments on an earlier draft of this article.
Address correspondence to Alyson H. Sheehan, ASPIRE Center for Learning and Development, 63 Old East
Neck Road, Melville, New York, 11747; E-mail: [email protected]

October 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 415

sessions is well understood as necessary for setting the stage for change in family therapy (Karam,
Ko, Pinsof, Mroczek, & Sprenkle, 2014; Sparks, 2014).
Retention has long been of interest to family therapy researchers, and many studies in Fried-
lander et al.’s (2011) meta-analysis of alliance in conjoint CFT used retention as the outcome of
interest. Why is retention a critical predictor of family therapy effectiveness? The simple answer is
that, compared to individual psychotherapy, in CFT there are more people who need to commit to
treatment. Studies of families with adolescents, in particular, consistently point to the salience of
retention in achieving successful outcomes (Liddle & Dakof, 1995; Stark, 1992). Moreover, engag-
ing and retaining adolescents in therapy, particularly those who abuse substances, is challenging.
Teens who resent authority figures often resist taking part, and if they do, they tend to view the
presenting problems and potential resolutions differently from their parents (Hawley & Garland,
2008; Lambert, Skinner, & Friedlander, 2012).
Since parental support is instrumental in facilitating adolescent engagement (Higham, Fried-
lander, Escudero, & Diamond, 2012; Marchionda & Slesnick, 2013) but parental over-involvement
or under-involvement can be detrimental (Robbins et al., 2009), how therapists balance multiple
alliances simultaneously needs to be understood. Two recent qualitative studies of interviews with
clients shed light on this question. The narrative themes from the earlier study (Lever & Gmeiner,
2000) indicated that clients who had dropped out reported feeling disconnected, distant, unsafe,
unsupported, and disempowered. These results are consistent with those of a more recent investi-
gation (Sheridan, Peterson, & Rosen, 2010), which identified factors that influenced clients to
attend the full course of therapy. Parent participants reported that at the outset of therapy, family
members tended to disagree about the nature of the problem, yet they kept coming to sessions
because the therapist was “caring, patient, and sincere” and provided direction while validating
each individual’s knowledge and perceptions.
Taken together, results of these studies underscore the point that family therapists need to
facilitate a supportive, collaborative environment for all participants in order to ensure retention.
Moreover, the qualitative results echo those with observational alliance data, which highlight the
salience of family collaboration in suggesting that a poor shared sense of purpose among family
members regarding the problems, goals, and value of therapy can result in poor outcomes or drop-
out (Beck, Friedlander, & Escudero, 2006; Lambert et al., 2012).
One challenge in developing a collaborative environment is that adults and children differ
developmentally (Friedlander, Escudero, Horvath et al., 2006). Arguing that working with adoles-
cents requires a developmentally sensitive approach, Diamond, Liddle, Hogue, and Dakof (1999)
identified three specific alliance strategies that seem to be key components of adolescent success in
multidimensional family therapy. As rated by observers, these strategies were attending to the ado-
lescent’s experience, establishing personally meaningful goals, and presenting as an ally. Presenting
oneself as an ally was the single most effective strategy in cases where the adolescent’s alliance with
the therapist improved over time. Although these findings are clinically important, Diamond et al.
focused exclusively on adolescents, without analyzing how the therapists simultaneously built and
maintained a strong alliance with the parents.
Our decision to investigate alliance in BSFT sessions was prompted not only by evidence of
the importance of this nonspecific factor in conjoint therapy, but also by the relative lack of family
alliance research in the context of manualized treatment (Friedlander, Heatherington, & Escudero,
in press). Based on the literature, we designed a mixed-methods study to explore if and how strong
alliances with individual family members, and with the family as a unit, would differentiate families
that continued in BSFT after Session 1 from those that dropped out.
Specifically, we focused on the ways in which strong, balanced alliances were achieved. To
control for individual therapist differences, we only studied therapists who worked with one
retained family and one nonretained family. In the quantitative aspect of the study, we examined
the sequential interactions of alliance-related behaviors within a three-minute window. Specifi-
cally, we predicted that only in the retained cases, (a) therapists’ positive behaviors would signifi-
cantly precede clients’ positive behaviors, and (b) clients’ negative behaviors would significantly
precede therapists’ positive behaviors. The latter hypotheses replicated the sequential analysis from
a previous study in which an experienced therapist worked with one positive and one negative out-
come case (Friedlander, Lambert, Escudero, & Cragun, 2008).

416 JOURNAL OF MARITAL AND FAMILY THERAPY October 2015

 In the qualitative aspect of the present study, four experts independently viewed randomly
assigned sessions without knowledge of the families’ retention status, after which they audiotaped
commentaries on the quality of each session in response to a set of guideline questions. Transcripts
of the commentaries were analyzed using consensual qualitative research methods (Hill, 2012), and
themes that emerged from the analysis were compared across groups in order to identify salient
alliance-related differences by family retention status.

METHOD

Participants
Families. In the multisite parent study (Robbins, Feaster, Horigian, Puccinelli et al., 2011),
246 adolescent substance abusers, aged 13–17 years, were randomly assigned to BSFT in eight
community agencies. Treatment was structured to consist of 12–16 sessions over a 4-month per-
iod, although many families were seen for up to 8 months due to difficulties in maintaining con-
sistent session frequency. The nature and severity of each family’s problems, along with
reported behavioral changes during treatment, were used to determine the appropriate length
of therapy. To be included in the study, an adolescent must have been referred for substance
abuse treatment or reported illicit drug use within the 30-day period prior to the pretreatment
screening.
From a pool of 41 previously identified English-speaking cases, we selected four therapists
who worked with one family that stayed in treatment and with one that dropped out after the first
session. All of the identified adolescents were boys, aged 14.3–17.8 years. The racial/ethnic back-
grounds and structure of the eight mostly single-parent families varied (one African American, five
Hispanic, and two White families). Notably, the demographic characteristics of the families were
also fairly well matched within the four therapists.
Therapists. The four master’s-level therapists represented three of the eight sites in the parent
study. Ranging in age from 40 to 47 years, three therapists were women, two were Latino, one was
White, and one was African American. Whereas three therapists were highly experienced (range
10–15 years), the fourth had 1 year of experience.

Brief Strategic Family Therapy

As an approach, BSFT (Szapocznik, Hervis, & Schwartz, 2003; Szapocznik & Kurtines,
1989), which is based on Minuchin and Fishman’s (1981) structural family therapy, is well suited
for studying the alliance. Compared with other approaches, BSFT specifically encourages the ther-
apist to “join with the family.” Moreover, efficacy research showed that BSFT tends to achieve
higher rates of engagement and retention than other community treatments (Coatsworth, Santiste-
ban, McBride, & Szapocznik, 2001). In particular, BSFT has shown considerable evidence of effi-
cacy in treating adolescent substance users (Santisteban et al., 2003). The approach places heavy
emphasis on systems, patterns of interaction, and strategy, involving various family members and
collaterals to ensure global, enduring change (Szapocznik & Williams, 2000).

System for Observing Family Therapy Alliances

The multidimensional, pantheoretical SOFTA, observer version (SOFTA-o; Friedlander,
Escudero, & Heatherington, 2006; Friedlander, Escudero, Horvath et al., 2006) was used to assess
client and therapist alliance-related behaviors. This rating tool was specifically developed for use in
conjoint therapy to assess the strength of alliance based on observable verbal and nonverbal
behaviors.
We used both the client and therapist versions of the SOFTA-o. The 43 client behaviors in this
system are assumed to reflect clients’ thoughts and feelings about the alliance, whereas the 44 ther-
apist behaviors are interventions that either contribute to or detract from the alliance. The specific
alliance-related behaviors, both positive and negative, are clustered within four dimensions:
ENGAGE, for example, “Client describes or discusses a plan for improving the situation,” CON-
NECT, for example, “Client has hostile or sarcastic interactions with the therapist,” SAFETY, for
example, “Client implies or states that therapy is a safe place,” and PURPOSE, for example, “Ther-
apist encourages clients to ask each other for their perspective.”

October 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 417

 To implement the SOFTA-o, trained raters independently observe videotaped therapy ses-
sions and record each time-stamped behavior as it occurs, referring to a training manual for opera-
tional definitions. Then, based on the valence, frequency, and meaningfulness of the observed
behaviors, the raters use a series of guidelines to assign global ratings, which range from 3 (extre-
mely problematic) to +3 (extremely strong), where a rating of 0 = neutral or unremarkable. Each
family member receives a global rating on ENGAGE, CONNECT, and SAFETY, and the family
unit receives a global rating on PURPOSE.
The client version of the SOFTA-o demonstrated known-groups, predictive and concurrent
validity with various outpatient samples (Friedlander, Escudero, Horvath et al., 2006). The thera-
pist version showed adequate face and content validity based on the responses of 29 researchers
(Friedlander, Escudero, and Heatherington, 2006); predictive validity was also supported by the
finding of a more extensive use of positive therapist behaviors in a good versus a poor outcome
case with the same therapist (Friedlander et al., 2008).
Two teams with two judges each, all graduate students in counseling psychology (3 women, 1
man), rated 26 videotaped sessions using the SOFTA-o, including the eight sessions that were used
in this study. Two teams were created to avoid rater bias and because the client and therapist
SOFTA-o systems are distinct.
Before the analysis began, each team was independently trained in the SOFTA-o by Myrna
Friedlander, the lead developer of the SOFTA rating system. Training involved rating a series of
practice sessions, including those available on the SOFTA website (http://www.softa-soatif.net),
and repeatedly calculating interrater agreement and reliability. Training continued until the raters
within each team achieved at least 80% agreement on the observed behaviors on a set of practice
videotapes. After the training was completed, each rater worked independently, observing the ses-
sions (in random order) and recording the exact time (on the video counter) at which each
observed behavior ended. The raters were not informed of the hypotheses, the treatment approach,
or that some families dropped out while others continued in treatment.
Interrater reliabilities for the team that observed the clients’ behaviors were as follows: .93
(ENGAGE), .91 (CONNECT), .91 (SAFETY), and .87 (PURPOSE). In the team that rated thera-
pists’ behaviors, the ICCs were .82 (ENGAGE), .90 (CONNECT), .78 (SAFETY), and .84 (PUR-
POSE). Within each team, the raters met frequently to compare results and to negotiate
disagreements to consensus. The consensus data were used in the final analyses.

Qualitative Method
Four clinical experts were remunerated $100 to take part in a study on “clients’ and therapists’
behaviors in initial family therapy sessions with adolescent substance abusers.” These individuals
(two women and two men; three social workers and one PhD-level psychologist) were selected
based on their experience (10–35 years) and professional specializations as family therapists. They
were not informed of the purpose of the study, the design, or that the therapists were using a BSFT
approach, nor were they told that that some families were retained in treatment whereas others
dropped out after the first session.
We randomly assigned experts to cases so that each judge observed one case in the retained
group and one case in the nonretained group conducted by different therapists. The two sessions
were viewed in random order. This procedure was devised to minimize the threat of expectancies
and to keep the experts unaware of the study’s purpose and design.
After observing each session, the experts audio-recorded their responses to 12 guideline ques-
tions adapted from Wildman (1994) to elicit general and specific perceptions of the quality of the
session and the therapist’s approach (see Appendix). The last question asked the experts to predict
the trajectory of the case based on what they had observed in the first session. The term alliance
was specifically not mentioned in the questions so as not to suggest its importance over other thera-
peutic processes. Audio recordings of the commentaries were used to provide rich and spontaneous
assessments of the sessions.
The narrative commentaries of all eight cases produced by the clinical experts were analyzed
using CQR (Hill, 2012), an inductive methodology for “studying in depth the inner experiences,
attitudes, and beliefs” of a small group of participants (p. 14). Two female PhD students in clinical
psychology who had experience in consensual qualitative research methods were the judges, and

418 JOURNAL OF MARITAL AND FAMILY THERAPY October 2015

the first and second author served as primary and secondary auditors. In preparation for the analy-
sis, the experts’ audio-recorded commentaries were de-identified and transcribed verbatim by the
first author.
First, as a group, the judges closely examined each of the eight transcripts line-by-line and
abstracted the content of each block of data. Then, the judges jointly developed a set of domains
based on these content areas, which was reviewed by the primary auditor. In the second round of
coding, the judges independently placed each block of data within a domain. Meetings were held
after each transcript was coded in order to compare codes and negotiate discrepancies. When con-
tent did not fit within an existing domain, the coders developed a new domain by consensus. The
primary auditor again provided feedback to the judges on this round of the analysis. Next, the
judges examined the blocks of data within each domain to develop and negotiate a list of core
ideas, which were then examined and used to create categories and subcategories to reflect the
themes of the data. The primary auditor checked the core ideas against the transcripts, and the sec-
ondary auditor reviewed and provided feedback on the categorization system.
After all the thematic categories and subcategories were renegotiated to consensus, the first
author identified those that were observed in each retention group. A theme was defined as salient
if it appeared in three or four of the commentaries in one group and in no more than one commen-
tary in the other group.

RESULTS

Observed Alliance (SOFTA-o)

Global ratings. First, we examined the therapists’ and clients’ global ratings by retention
group. No negative therapist behaviors were observed in any of the sessions. Rather, the therapists
worked hard in all of their cases to increase family members’ ENGAGE and CONNECT (the
majority of therapist ratings on these dimensions were +2 or +3). It is notable, however, that on the
two dimensions that are unique to conjoint therapy, SAFETY and PURPOSE, the therapists in
both groups had lower ratings (with one exception, all were 0 or +1), suggesting that the therapists
were paying considerably less attention to the systemic aspects of the alliance and more attention
to engaging and connecting with individual family members.
In terms of clients, there was no clear pattern of alliance ratings, either in terms of individuals
or in terms of the family unit. In three of the four retained cases, the adolescents’ alliance ratings
were either neutral or positive on ENGAGE and CONNECT, but in the other case, the adolescent
received problematic alliance ratings on all three dimensions. In two of the nonretained cases, the
adolescents’ alliance was rated as problematic on these dimensions. Across the sample, the parents’
alliance ratings were strong, with the exception of one mother in the retained group. Notably, in
seven of the eight families, when the adolescent or a parent had a negative SAFETY rating, the
family’s PURPOSE rating was also problematic. Interestingly, there was a remarkable difference
between the retained and nonretained groups on this dimension. Among the retained families,
PURPOSE ratings were slightly problematic ( 1) in three cases and neutral (0) in the fourth case,
whereas among the nonretained families, scores were slightly positive (+1) in three cases and
slightly problematic ( 1) in the fourth case.
Contingent client/therapist behavioral sequences. The Sequential Data Interchange Standard
(SDIS) was used in combination with the Generalized Sequential Querier (GSEQ; Bakeman &
Quera, 1992) to test the significance of the contingent probabilities of alliance-related behaviors.
The sequential analysis involved constructing two transitional probability matrices using the fre-
quencies of positive and negative client and therapist SOFTA-o behaviors across the eight sessions
(see Tables S1 and S2 in Supporting information). A transitional probability matrix organizes con-
ditional data in a time lag format in order to assess the significance of Time 2 (the columns, which
denote the conditional, or consequent behaviors) given Time 1 (the rows, which denote the uncon-
ditional, or antecedent behaviors). In our analyses, one matrix was therapist positive behav-
ior ? client positive behavior, and the other matrix was client negative behavior ? therapist
positive behavior within a 3-min window.
The SDIS and GSEQ programs use the timed-event data to compare the conditional proba-
bilities of behaviors with their unconditional probabilities in order to determine whether the

October 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 419

antecedent behaviors significantly precede the consequent behaviors more so than would be
expected by chance. Since contingency, or the temporal precedence of behaviors, is preserved in
this kind of sequential analysis, a significant result provides stronger support for causality than a
traditional correlational design.
Results for both analyses (therapist ? client and client ? therapist) were nonsignificant,
v2(2) = 0.46, p = .80, and, v2(1) = 3.18, p = .07, respectively. Since the latter analysis approached
significance, we inspected the cells of this matrix, which showed that (a) the therapists’ positive alli-
ance behaviors preceded clients’ positive alliance behaviors somewhat more often in the nonre-
tained cases (65% of the time) than in the retained cases (49% of the time) and that (b) the
therapists responded positively to negative client behavior 61% of the time in their four retained
cases but failed to respond positively 60% of the time in their four nonretained cases.

Qualitative Themes Characteristic of Each Group

The eight domains that emerged from our analysis were Orientation to the Process, Gathering
Information, Family Engagement, Rapport, Emotional Atmosphere, Within-Family Dynamics,
Interventions, and General Perceptions. In each domain, the core ideas were clustered within cate-
gories and subcategories. In the following discussion, we describe only the salient themes, that is,
those that appeared in three or four of the commentaries in one group and in no more than one
commentary in the other group. (There was no consistent “outlier” case in either group across the
18 salient themes.) The full list of categories and subcategories by retention group can be found in
Table S3, Supporting information.
Orientation to the process. Within this domain, one subcategory was salient: therapist’s failure
to structure the session. This subcategory emerged in all four of the nonretained cases and in none
of the retained cases. Judges’ commentaries included, “There’s absolutely no structure to the ses-
sion” (Judge 3, Case 4NR) and “She [therapist] seemed to be randomly putting these comments
and these questions out there and, for a while, there was not much focus on what she was trying to
achieve” (Judge 1, 2NR).
Gathering information. Within this domain that described the therapists’ process of gathering
information about the family, two subcategories within the category Feelings and experiences were
salient. First, therapist explored feelings and experiences emerged in four of the retained cases but
only one of the nonretained cases. Commentaries related to this subcategory indicated both rela-
tionally and individually based interventions, including “She [therapist] went after the feelings that
the situation brought about” (Judge 4, Case 4R) and “He [therapist] tried to get them to explore
their feelings about the issues” (Judge 2, Case 2R).
Second, the subcategory therapist failed to explore feelings and experiences emerged in three of
the nonretained cases but not in any of the retained cases. Commentaries from the judges included,
“Let’s just say he’s. . .not allowing the adolescents to express their feelings” (Judge 1, 2NR) and
“she [therapist] just wouldn’t go there. . .exploring the different perspectives and experiences, and
how each of them had a certain validity” (Judge 3, Case 4NR).
Family member engagement. Within this domain, the only salient category was Parents
actively involved, which emerged in three of the retained cases but in none of the nonretained cases.
Judges made comments such as, “The therapist engaged the parents pretty well” (Judge 4, Case
4R) and “The father was clear in expressing how he felt throughout the session” (Judge 3, Case
3R).
Rapport. Of five categories related to rapport between the therapist and family members, two
categories were salient, as were three subcategories. Core ideas in the category Therapist pulled
member(s) into discussion emerged in all of the retained cases but none of the nonretained cases.
Judge 2 noted, “The therapist did make a point to engage with each of the individual family mem-
bers” (Case 2R), and Judge 3 observed, “The therapist’s primary purpose in this session was to
make everybody feel involved, help everybody feel included” (Case 3R).
Both subcategories encompassed within the category Therapist/family connection were salient.
The subcategory clear connection emerged in all four of the retained cases but none of the nonre-
tained cases. Commentaries included, “She [therapist] tried to make everyone feel welcome and
comfortable” (Judge 4, Case 4R), and “The therapist made a point to connect with them and
accept their different views and opinions” (Judge 3, Case 3R).

420 JOURNAL OF MARITAL AND FAMILY THERAPY October 2015

 The subcategory of apparent disconnection emerged in three of the nonretained cases and none
of the retained cases. Examples of commentary that reflected this subcategory included, “The rela-
tionship between the therapist and the clients just didn’t seem to quite ever gel” (Judge 2, Case
3NR) and “She [therapist] seemed removed and distant, more like a journalist than a therapist”
(Judge 4, Case 1 NR).
The subcategory offered support to family members, in the category of Therapist support, was
salient in three of the retained cases and none of the nonretained cases. Commentaries included,
“She [therapist] was absolutely there for a reason, and it felt like they knew she was there to help
them” (Judge 1, Case 1R)” and “She [therapist] was attentive and supportive about how everyone
felt about [name of adolescent] and about the problems that had come from his actions” (Judge 3,
Case 3R). Likewise, the category: Therapist expressed feeling connected to family was salient in
three of the retained cases and none of the nonretained cases. Judge 1 (Case 1R) stated that, “She
[therapist] didn’t break down crying with them; however, she appeared to be affected emotionally
when a tear rolled down her eye, and I think that was quite magical for the young man as well as
the aunt.” In Case 2R, Judge 2 observed, “She [therapist]. . .showed that she experienced a bond
with them.”
Emotional atmosphere. Of the four categories within this domain, one category and one sub-
category were salient. In the area of Safety, the subcategory high safety evident emerged within
three of the retained cases but in none of the nonretained cases, for example, “She [therapist]
appeared to provide a safe environment to begin with that allowed for a lot of healing” (Judge 1,
Case 1R) and “It ended with this feeling had a safe place for an equal say and had been fairly well
respected by the other members of the group” (Judge 3, Case 3R). In addition, the category Thera-
pist maintained control was observed in three retained cases but no nonretained cases. Examples
included, “She [therapist] maintained a sense of competency and control” (Judge 4, Case 4R) and
“It was clear that she had a direction she was going into” (Judge 1, Case 1R).
Within-family dynamics. Within this domain, the only salient category was Discussed shared
contribution to the problem, which emerged in three of the retained cases and one of the nonre-
tained cases. Examples included, “The therapist. . .was talking about the dysfunctional behaviors,
the kids not cooperating with doing their tasks, the other stuff that each family member is doing
that adds to the problem” (Judge 2, Case 2R) and “The therapist really got to, talked about what
the relationships are between each person that is maintaining these issues” (Judge 4, Case 4R).
Interventions. Ten therapeutic interventions were captured in this domain, of which six cate-
gories were salient. Acknowledged strengths of family emerged in three of the retained cases but
none of the nonretained cases. The judges commented that “She [therapist] pointed out their
strengths to them” (Judge 3, Case 3R) and “She [therapist] used several examples where she
stopped and said, ‘This is where you did really good’” (Judge 2, Case 2R). In three of the retained
cases but none of the nonretained cases, Validated and normalized family struggle was observed.
Judges’ commentaries included, “He [therapist]. . .gave them a tremendous amount of validation
for what they had been through on their journey and what got them there” (Judge 2, Case 2R) and
“She did a great job normalizing his feelings. . .she could see that he was clearly depressed, she nor-
malized it” (Judge 1, Case 1R).
The category Provided information/education emerged in all four of the retained cases but none
of the nonretained cases. Judges’ comments about the retained cases included, “She [therapist] edu-
cated the family about how therapy works and how they could apply what they learned in different
ways” (Judge 3, Case 3R) and “There was an effort on the part of the therapist to do a little didac-
tic lecture to start” (Judge 4, Case 4R).
Asking closed-ended questions emerged in three of the nonretained cases but was not noted in
any retained cases. Examples of the judges’ commentary within this category included, “The big
thing was his [therapist] stepping in continually and asking closed-ended questions” (Judge 1, Case
2NR) and “She [therapist] asked so many yes or no questions, and once they were answered that
was kind of the end of that” (Judge 2, Case 3NR).
Another salient category that emerged in three of the retained cases and just one of the nonre-
tained cases was Missed opportunities. Core ideas in this category involved the experts’ commen-
tary on areas that could have been pursued further, such as “I think she [therapist] missed a couple
of things, that there were certain feelings going on in the room not addressed directly” (Judge 3,

October 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 421

Case 3R) and “I think that the themes were consistent and she did go after many areas but still had
chances that she didn’t take to go into some others” (Judge 1, Case 1R).
The final salient category in this domain, Addressed resistance, emerged in all four of the
retained cases but none of the nonretained cases. Commentaries that were encompassed in this cat-
egory included, “The one kid said ‘I don’t care,’ and he [therapist] took it and went forward with
confronting it” (Judge 2, Case 2R), and “The therapist showed that she was willing to address why
they felt they did not want to be there” (Judge 4, Case 4R).
General perceptions. Within this final domain, the salient category was Positive perception of
session or therapist, which emerged in three retained cases and in none of the nonretained cases.
Experts’ observations included, “I don’t think she could have done much better in the session”
(Judge 1, Case 1R), “I thought that the session was generally successful” (Judge 3, Case 3R), and
“I think actually the therapist did a very good job of basically tying everything up” (Judge 2, Case
2R). It was also noted that, in the category Prediction of retention in treatment, which contained
the experts’ responses to the last guideline question, accurate predictions about the families’ reten-
tion status were made for two of the cases in each group.

DISCUSSION

The goal of this mixed-methods study was to examine first BSFT sessions, matched by thera-
pist to control for individual therapist differences, using an observational alliance rating system
and a qualitative analysis of experts’ general commentaries on the sessions. Although the retained
group did not differ significantly from the nonretained group in terms of overall alliance ratings or
contingent interactions, there were notable consistencies between the qualitative and quantitative
aspects of the study. These consistencies support the validity of the results, which reflect the alli-
ance literature in general (Fife et al., 2014; Karam et al., 2014; Sparks, 2014) and the SOFTA-o lit-
erature specifically (Beck et al., 2006; Friedlander, Escudero, Horvath et al., 2006,
2008Friedlander et al., 2008). Moreover, the consistent results have important implications for
therapists working with challenging families.

Theoretical and Practical Implications of the Results across Methods

Most of the salient qualitative themes, that is, those that were characteristic of the retained
families but not of those that dropped out after the first session, reflect aspects of the therapeutic
alliance in the literature, that is the importance of facilitating engagement along with emotional
connection and the intertwining of therapist qualities with technique (Fife et al., 2014). Moreover,
the qualitative themes are also captured by the four SOFTA dimensions (Friedlander, Escudero,
and Heatherington, 2006). These consistencies are particularly meaningful because the experts
who observed and commented on the sessions were not informed of either the treatment approach
or the study’s focus on alliance. Specifically, the SOFTA dimension ENGAGE was evident in the
qualitative categories parents actively involved, therapist pulled family member(s) into discussion,
therapist clarified process and roles, family member(s) expressed belief in therapy, and therapist
addressed resistance. Safety within the Therapeutic System was evident in high safety evident (ver-
sus little or no safety), therapist maintained control, and therapist structured (or failed to structure)
the session. Shared Sense of Purpose within the Family was evident in family discussed shared con-
tributions to problem, caregiver-child problems displayed, and therapist acknowledged strengths of
the family. Finally, Emotional Connection with the Therapist was evident in therapist/family con-
nection (or apparent disconnection), therapist offered support, therapist expressed feeling connected,
and therapist validated/normalized the family’s struggle. The variety of ways in which the therapists
attempted to connect with their clients is consistent with the SOFTA-o ratings, which indicated
that the therapists focused more on this aspect of alliance than on the other three across sessions.
The focus on creating connections is also consistent with results of prior CFT alliance research,
which emphasized the critical nature of the emotional bond (Lever & Gmeiner, 2000; Sheridan
et al., 2010), particularly with adolescents (Diamond et al., 1999).
As a complement to the therapists’ attempts to connect with family members, the qualitative
themes also revealed that in the retained cases the therapists maintained an authoritative role as
“expert,” which may be one reason that greater safety for family members was observed in these

422 JOURNAL OF MARITAL AND FAMILY THERAPY October 2015

cases. That is, therapist maintained control, provided information and education, and addressed resis-
tance emerged as salient only for the retained cases, whereas poor and unclear session structure was
a salient feature of the nonretained cases.
Of note, the experts’ overall perceptions were more positive for the retained group. This global
judgment is reflected in several of the salient themes that reflected negative versus positive thera-
peutic processes. Only in the retained families did the therapists explore feelings/experiences,
express their emotional connection, maintain control, address resistance, acknowledge the family’s
strengths, and validate the family’s struggle. Only in the nonretained families were the therapists
visibly disconnected from the family; they failed to structure the session and failed to explore individ-
uals’ feelings or experiences; they used closed questions; and they missed opportunities for interven-
tion. The “take home” message for practitioners and clinicians in training is that, in addition to
engaging and connecting emotionally with all family members, failure to promote safety and
within-family collaboration may contribute to lack of progress (cf. Escudero, Friedlander, Varela,
& Abascal, 2008) or dropout (cf. Beck et al., 2006).
Also of note, many alliance-related processes commented on by the experts did not emerge as
salient, that is, these processes were not more characteristic of one group or the other. With respect
to facilitating engagement, for example, the groups did not differ in the extent to which the thera-
pists identified the problem and clarified process and roles. Also reflecting engagement, family mem-
bers in the two groups did not differ in that all members participated and family member(s)
expressed a belief in therapy. Observation of these aspects across the sample is consistent with the
SOFTA-o global ratings, which showed that family members in both groups were generally quite
engaged in the session.
Despite the nonsignificant sequential analyses of SOFTA-o interactions, the observed fre-
quencies were interesting. That is, although the therapists’ positive alliance behaviors preceded cli-
ents’ positive alliance behaviors somewhat more often in the nonretained cases than in the retained
cases, clients’ negative behaviors preceded therapists’ positive behaviors more often in the retained
cases. The therapists’ positive responses following client displays of negative alliance behavior, a
sequence that reflects rupture repair (cf. Escudero et al., 2012), may be one element that contrib-
utes to retention in conjoint therapy. In BSFT in particular, the challenge for the therapist is to eli-
cit enough negative within-family behavior to observe the pattern of interactions, yet not so much
negativity that the alliance is irreparably strained.
The analyses, quantitative as well as qualitative, suggest that observations of alliance-related
behaviors are insufficient predictors of retention. Whereas the SOFTA-o is useful for examining
microbehavioral exchanges between clients and therapists, clinical experts seem better able to iden-
tify the more subtle aspects of a session.

Strengths and Limitations of the Study

A number of elements in the design and procedures of this study strengthened its validity. All
of the sessions were drawn from a manualized and closely supervised treatment within a multisite
clinical trial. Furthermore, matching each retained case with a nonretained case seen by the same
therapist enhanced internal validity in that, essentially, the therapists served as their own controls.
Another strong design feature was that, in the eight sessions selected for comparison, the families
were closely matched demographically, and all of the substance abusers in our sample were boys.
In terms of assessing alliance-related behavior during family therapy sessions, observer ratings
are often a better predictor of outcome than either therapists’ or clients’ self-report (Beck et al.,
2006; Robbins et al., 2009). The observation system (SOFTA-o) used in this study to rate behav-
iors within four dimensions of the alliance has shown consistent predictive value in reflecting cli-
ents’ and therapists’ self-reported alliance perceptions, therapeutic progress, and treatment success
(Escudero et al., 2008). By assessing alliance-related behavior in the context of manualized treat-
ment, the present study furthered SOFTA-o research, the bulk of which has been conducted within
“treatment as usual.” The trained raters were in two teams, one that rated client behavior and one
that rated therapist behaviors. These raters were unaware of the purpose of the study and the fami-
lies’ retention status, minimizing expectancy bias. Incorporating both the global ratings and the
specific instances of client and therapist behaviors allowed for a multilevel assessment of the thera-
peutic alliance processes present within the sessions. Finally, triangulation was implemented, with

October 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 423

observer ratings based on an established coding system and qualitative themes generated from
family therapy experts.
The inclusion of a qualitative analysis of the experts’ commentaries complemented the quanti-
tative analysis of the behavioral features observed in the retained and nonretained cases. The clini-
cal experts who commented on the sessions were experienced psychotherapists, with varied
theoretical orientations, who specialized in family treatment. They were randomly assigned to one
case from each group, so that they were unaware that the therapists served as their own controls.
Like the trained observers who rated the alliance, the experts were not informed of the purpose of
the study, treatment approach, or families’ retention status.
Despite these strengths, the present study had some notable limitations. The small sample was
selected based on availability, limiting generalizability. The demographic characteristics of the
families (e.g., all identified adolescents were boys) and therapists in the sample, as well as a specific
presenting problem, prevent broad generalization within family therapy practice. Our inclusion of
only those therapists who saw both a retained and a nonretained BSFT case may not accurately
represent the therapists’ skill levels within the larger clinical trial.
Although the examination of retention is clearly salient for research in psychotherapy, other
components of treatment outcome were not included in this study. Therefore, in spite of the crucial
impact of retention on influencing treatment outcome, the relation of alliance to outcome was not
studied in this investigation.
The observational data, while aligned with the qualitative data, did not provide as rich a pic-
ture of these first sessions. Indeed, the clinical experts revealed many subtle processes related to the
alliance in these eight cases that may not be captured in the SOFTA-o. The nonsignificant compar-
isons of the SOFTA-o ratings might be due to insufficient statistical power or the use of a three-
minute window for the sequential analyses, especially since significant sequential results with the
SOFTA-o were previously found in a larger sample of sessions using the same time frame (Fried-
lander et al., 2008).
Furthermore, we acknowledge that in addition to alliance, any number of other factors,
including events occurring outside the therapeutic context, may encourage or discourage a family’s
continuation in treatment. For example, a family discussion after the first session, such as an argu-
ment over information that one family member disclosed to the therapist, could be the pivotal fac-
tor in a family’s decision about whether or not to continue in treatment. The availability of
transportation, housing, legal, financial, and medical concerns are other plausible reasons for
treatment discontinuation, apart from what takes place in an initial session. Previous research sug-
gests that relation of alliance to retention in family therapy for adolescent substance use functions
differently based on clients’ racial and ethnic characteristics (Flicker, Turner, Waldron, Brody, &
Ozechowski, 2008). Since the influence of these characteristics could not be examined in the present
design, it is not known whether the mixture of same-race and different-race therapists and families
played a role in the families’ retention status. The importance of studying racial and ethnic culture
in the context of CFT alliance research cannot be overstated (Quirk, Owen, Inch, France, & Ber-
gen, 2014).
It is also important to note that although observers’ perceptions of alliance in family therapy
are valid predictors (Robbins et al., 2006), relying solely on observers does not take into account
clients’ or therapists’ phenomenonological experiences of the alliance. Nonetheless, the use of
expert family therapists provided a valuable additional data source.

Recommendations for Future Study

Research that examines the role of therapeutic alliance in family therapy with adolescents is
still in its infancy, leaving many areas open for exploration. This study examined the relationship
between therapeutic alliance behaviors and retention within a small sample of cases that received a
specific, manualized treatment for a single presenting concern. A primary recommendation for
future study concerns the value of investigating common factors alongside specific factors in effec-
tiveness research. Considering alliance data along with fidelity indices provides a richer picture of
family therapy processes than either measure in isolation. The contribution of therapeutic alliance
to retention in a larger sample and a broader client population should also be examined. Some
descriptive trends, particularly in the sequential behavior patterns, were limited in statistical power

424 JOURNAL OF MARITAL AND FAMILY THERAPY October 2015

due to the small sample size. Conducting sequential analyses of client and therapist behavioral
exchanges in a larger number of cases could clarify patterns detected in the present investigation
and in a similar study (Friedlander et al., 2008).
By focusing solely on the initial session of family therapy, this study provided only a brief
snapshot of the treatment process. Much richer information about the development of the alliance
over time and in relation to retention may be gained from examining changes and progress across
continued sessions. In particular, there was some evidence that the rupture and repair process, as
well as the balance between explicating family problems and resistance while providing warmth
and support, were major factors that differentiated the families that returned after the initial ses-
sion from those that did not. Further research is needed to examine these processes more closely
and to identify the rupture repair process over many sessions.
Observer ratings and clinical expert commentary were used in this study based on their value
in assessing session processes from a fairly objective standpoint. However, including self-report
from therapists and family members in future research would allow for detection of clients’ and
families’ experiences that may influence treatment continuation. Indeed, as one anonymous
reviewer suggested, a worthwhile direction for future study is to ask therapists for their perspective
on matched cases that did or did not commit to treatment.
Although an effort was made to match retained and nonretained cases that had similar demo-
graphic characteristics, it was impossible to rule out the many alternative explanations for the fam-
ilies’ retention status. Future research should control for other factors, such as mandated
attendance, transportation availability, and residential stability, in order to gain a clearer sense of
the strength of in-session processes as they influence a family’s retention in treatment.
Additionally, the role of families’ racial and ethnic identities should be studied to clarify
potential cultural factors that might influence the role of alliance in retention in family therapy.
Finally, the scope of the present study did not consider alliance in relation to outcome; doing
so in future research would deepen our understanding of the processes that are not only associ-
ated with treatment continuation but also with a family’s gains made as its treatment pro-
gresses.
In sum, the present mixed-methods investigation provides a clinically rich understanding of
multifaceted alliance building in the context of manualized family therapy, highlighting the subtle
and not-so-subtle therapist behaviors that characterize a relatively successful “way of being” (Fife
et al., 2014) with a family. More specifically, our results underscore the need to carefully balance
the “expert” role with forming emotional bonds with each client and with promoting an open fam-
ily discussion of resistance and barriers to change in the context of their shared understanding of
treatment goals.

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APPENDIX

GUIDELINE QUESTIONS FOR CLINICAL EXPERTS (ADAPTED FROM

WILDMAN, 1994)
1. Comment on the overall tone of the session.
2. Comment on the relationship between the therapist and clients.
3. Comment of the characteristics of the therapist–client interactions and its meaning.
4. Comment on the skills, behavior, and characteristics of the therapist that influenced the
session/treatment.
5. Comment on the accuracy and adequacy of the therapist’s strategies.
6. Comment on the skills, behaviors, and characteristics of the clients that impact on the
sessions/treatment.
7. Comment on the themes of the session and the consistency with which themes were pur-
sued.
8. Comment on areas left unexplored by the therapist.
9. Comment on anything that struck you as salient, interesting, illuminating, or important
about this session.
10. Comment on the degree to which the clients’ problems were effectively addressed in this
session.
11. Comment on the general success of the session.
12. Predict the outcome of this treatment if it were to continue in the same vein.

October 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 427

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