This study aimed to examine the process of engagement of youth and family members in a series of family therapy sessions delivered in the home environment. Considered together, our findings suggest complex relationships between family members’ alliances with the therapist and among family members themselves. Even though qualitative interviews conducted for this study were not collected with an a priori focus on therapeutic alliance, participant interviews suggested the importance of building relationships during the treatment process. This finding supports previous research suggesting that a strong therapeutic alliance significantly predicts outcomes, over and above the type of therapy administered, the length of treatment, or any other single aspect of the therapeutic process (Shelef, Diamond, Diamond & Liddle, 2005
Limited research has compared parents and youths concerning their experiences and perceptions of family based treatment. Thus, this study sought responses and perceptions of parents and youths engaged in family therapy. Findings demonstrated that they identified surprisingly similar categories of engagement. For both, task-centered engagement was vital for learning new methods of managing family life. Although parents were more verbal in their descriptions, youths commented primarily on “tasks” the therapist modeled and encouraged them to develop, such as new skills and insights related to family relationships and communication. For parents, therapeutic tasks that focused more broadly on parenting skills, such as teaching effective listening, providing guidance, and developing insights related to adolescent behavior were viewed as particularly helpful.
Therapeutic alliance that focused on relationship-building was discussed by most parents, but fewer adolescents. Parents had an affinity for therapists who had a calm and casual presence because it increased their level of comfort in family therapy sessions. Youths also appreciated the calming influence of therapists that improved their level of comfort with them, and favored therapists who appeared authentic, caring, and impartial.
Intra-family engagement, reflected in the building of familial relationships, appeared to improve through involvement in the family based therapy. Parents enjoyed bonding, spending time together as a family, and communicating more respectfully and positively with their child(ren). They valued learning more about their child(ren) and understanding their unique strengths and perspectives. Youths also mentioned their enjoyment of the time spent together as a family during family therapy sessions, adding that feeling connected and learning about commonalities and mutual interests among family members was a new experience. Therapy sessions often elicited discussion of information the family members previously had not discussed with one another. Similar to other research (Azrin, Donohue, Besalel, Kogan & Acierno, 1994
; Liddle et al., 2001
), improvement in parent-adolescent relationships and positive family interactions was an encouraging outcome of the family therapy sessions.
A challenge in understanding engagement in family therapy is the complex multi-person, multi-generational systems involved in treatment; no single individual can be considered in isolation (Beck et al., 2006
). Recent literature on therapeutic alliance in family therapy emphasizes the need to consider the multiple, dual, and sometimes competing alliances that develop between child and therapist and parent and therapist (Diamond et al., 1999
). In this study it appeared that the family therapy sessions seemed not only to build trust and appreciation for the therapist but also encouraged the development of stronger connections among family members. Youth participants, often viewed as resistant to treatment, noted that having an “unbiased,” “respectful,” “supportive”therapist encouraged them to discuss sensitive information within family sessions. Parents also noted greater understanding and expressions of warmth for their adolescent child when the therapist helped modulate negative interactions. Thus, recognizing the important role that parents play in treatment engagement in relation to their child(ren) (Kazdin et al., 1990
) and the role the youth plays in the therapeutic encounter is vital for therapy to be successful. Although this complexity creates a challenge for family therapists who must build alliances with the youth and the parent, relationship-building with family members is crucial.
Although most families were able to build a positive alliance with their therapist and with other family members, the difficulties a few families reported in engaging in the therapeutic process indicate the various challenges of building an alliance. For example, therapists must develop a relationship with a variety of family members when conducting family therapy; difficulties may arise due to varied levels of commitment among family members. Participants’ comments suggested that some families or family members were unable to cope with the intense emotions or sensitive subject matter often brought out during family therapy sessions and simply disengaged from the treatment process. These concepts appear to be reciprocal such that families initially resistant to therapy may avoid engaging in treatment, which makes future sessions overwhelming and creates more resistance. Studies suggest that confronting negative client responses to therapists can improve alliance development and engagement (Beck et al., 2006
; Digiuseppe et al., 1996
). Transforming resistance and reluctance into a collaborative relationship with the therapist is one of the first and most critical tasks in the therapeutic process (Diamond et al., 1999
The interrelationship between therapist-oriented alliances and family oriented alliances is an area for further research. What remains unclear is whether alliances with the therapist create opportunities and models for family members to build alliances with one another or whether developing a bond among members is what makes families more invested in the change process and thus better able to bond with their therapist. While the direction of these relationships is unclear, the results of this study indicate that developing both therapist and family oriented alliances enhances client engagement in the therapeutic process.