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Therapeutic Alliance in FamilyTherapy for Adolescents withEpilepsy: An Exploratory StudyRobert L. Glueckauf , Heidi J. Liss , Diane E. Mcquillen , PatM. Webb , Jeanne Dairaghi & Carol B. CarterPublished online: 30 Nov 2010.

To cite this article: Robert L. Glueckauf , Heidi J. Liss , Diane E. Mcquillen , Pat M. Webb ,Jeanne Dairaghi & Carol B. Carter (2002) Therapeutic Alliance in Family Therapy forAdolescents with Epilepsy: An Exploratory Study, The American Journal of Family Therapy,30:2, 125-139, DOI: 10.1080/019261802753573849

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The American Journal of Family Therapy, 30:125–139, 2002Copyright © 2002 Brunner-Routledge0192-6187/02 $12.00 + .00

This project was funded by a National Institute on Disability and Rehabilitation Researchgrant (H133C20035) to Robert L. Glueckauf.

Address correspondence to Robert L. Glueckauf, Ph.D., Department of Clinical andHealth Psychology, PO Box 100165, Gainesville, FL 32610-0165. E-mail: rgluecka@hp.ufl.edu

125

Therapeutic Alliance in Family Therapyfor Adolescents with Epilepsy:

An Exploratory Study

ROBERT L. GLUECKAUF and HEIDI J. LISSUniversity of Florida, Gainesville, Florida, USA

DIANE E. MCQUILLEN, PAT M. WEBB, JEANNE DAIRAGHI,and CAROL B. CARTER

Indiana University and Purdue University, Indianapolis, Indiana, USA

Nineteen adolescents with epilepsy and their parents completed allphases of the study. Families were assigned randomly to either is-sue-specific single-family counseling (IFCM) or to a multi-familypsychoeducational group (PG). Three issue-specific scales were usedto evaluate problem improvement. A modified version of the Work-ing Alliance Inventory assessed therapeutic alliance. No overall dif-ferences in alliance were found between IFCM and PG. However,IFCM adolescents reported significantly stronger alliance than thosein PG. Alliance remained stable from sessions three to six. Finally,there was a trend for alliance to correlate positively with therapyoutcome for teens, but not for mothers.

Over the past decade, the therapist–client relationship or “therapeutic alli-ance” has emerged as one of the most important areas of concentration ofpsychotherapy process research. Therapeutic alliance refers to the collabora-tive efforts of the therapist and client, which are characterized by a mutualperception of caring and concern, as well as the belief that they can workproductively toward a shared goal (Heatherington & Friedlander, 1990). Thera-peutic alliance has focused primarily on individual psychotherapy and hasbeen shown across several studies to be significantly related to client im-provement (e.g., Horvath & Luborsky, 1993; Horvath & Symonds, 1991).Research on the role of therapeutic alliance in other therapeutic modalities

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(e.g., family therapy, group therapy, and marital therapy) has emerged onlyrecently. Although several investigators (e.g., Heatherington & Friedlander,1990; Pinsoff & Catherall, 1986) have argued that therapeutic relationshipfactors are critical to our understanding of the linkages between process andoutcome in family therapy, we have only limited knowledge about how andunder what conditions therapeutic alliance impacts family therapy outcomes.Furthermore, we currently have no data about the relationship between thera-peutic alliance and family therapy outcomes for at-risk adolescents with chronicdisabilities who present with significant psychosocial and emotional problems.

What is the theoretical basis for the development of the therapeuticalliance? Therapeutic alliance has its roots in psychodynamic theory (Horvath& Luborsky, 1993). However, various theoretical approaches seem to concurin their ideas about how alliance develops: alliance is theorized to developfrom client perceptions of the therapist or the therapeutic situation, whetheror not these perceptions are accurate (Horvath & Luborsky, 1993). Althoughthe exact mechanism by which therapeutic alliance leads to therapeutic changeis unknown, it could be implied that beliefs can impact motivation and be-havior in the therapeutic setting.

What do we know about the therapeutic alliance from the researchliterature, and what are the potential implications for family therapy withadolescents with chronic disabilities? Previous research has suggested thatthe therapeutic alliance is not generally influenced by the type of individualpsychotherapy (Horvath & Symonds, 1991; Krupnick et al., 1996). However,the generalizability of these findings to multi-client forms of therapy, such asfamily therapy, is unclear. Furthermore, no studies to date have examinedthe relationship between alliance and outcome for individuals with disabili-ties. We currently lack basic information about the effects of different typesof family therapy on the development of therapeutic alliance, particularly infamilies who have a disabled member.

Several studies (e.g., Horvath & Luborsky, 1993; Ryan & Cicchetti, 1985)have indicated that therapeutic alliance is typically established by the thirdsession of treatment. The impact of alliance has been examined in treat-ments ranging from 4 to 50 sessions. The length of treatment, however, didnot significantly mediate the relationship between strength of alliance andtherapeutic outcome (Horvath & Luborsky, 1993), at least in individual psy-chotherapy. This lack of association may not hold, however, for otherforms of therapy, such as family and group therapy, in which therapeuticcontact between clients and therapist may be distributed across several indi-viduals. Therapeutic alliance may take longer to develop, or may possibly beconstrained because of the limited attention that the therapist can direct to agiven individual in a multi-client situation.

We have only limited knowledge about the effects of phase of life onthe development of therapeutic alliance. Although several studies have em-phasized the importance of establishing a therapeutic alliance with adoles-cents (e.g., Johnson & Alford, 1987; O’Malley, 1990), there have been no

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Alliance in Family Therapy for Teens with Epilepsy 127

empirical investigations examining differences in the intensity of the thera-peutic alliance between adolescents and parents. It is not clear what impactthe presence of an adolescent, who is striving for independence and possi-bly unenthusiastic about attending therapy (Rae, 1992), has on the develop-ment of the working alliance between parents and therapists. Clinical lorehas suggested that the establishment of agreement among all parties onacceptable tasks and goals may be more difficult to achieve under thesecircumstances. Note also that, to date, no studies have examined differencesbetween adolescents with disabilities and their parents on the three compo-nents of alliance (i.e., agreement on therapy goals, therapist’s facility in orga-nizing tasks, and the therapist–client bond) and their relationship with treat-ment outcome.

The primary purpose of the current study was to examine the effects ofdifferent forms of family therapy, timing of assessment, and type of rater onthe working alliance between families of adolescents with disabilities andtheir counselors. The specific disability of interest was recurrent epilepticseizures, commonly known as seizure disorder. Epilepsy is the second mostprevalent neurological condition of childhood and adolescence (Hauser &Hesdorffer, 1990). There is mounting evidence that adolescents with epi-lepsy are particularly at risk for the development of mental health problems.Several researchers have shown that adolescents and children with seizuredisorders have significantly more behavioral problems (Austin, 1989; Hoare& Kerley, 1991), psychiatric disturbances (Hoare, 1984; Scott, 1978), andpoorer self-concept (Margalit & Heiman, 1983; Matthews, Barabas, & Ferrari,1982) than both their non-disabled and chronically disabled peers.

The developmental tasks of adolescence include separation from fam-ily, identification with peers, and the management of independence. Thedifficulties associated with successful completion of these tasks are substan-tial for most adolescents, but are further compounded for teenagers withepilepsy who may be faced with restrictions of recreational and social activi-ties, difficulties obtaining a driver’s license, heightened dependence on care-takers, and being different from peers. Uncontrolled seizures also can leadto disruption of schooling, which in turn may produce further stress andconflict among adolescents and their parents. Thus, epilepsy may pose sig-nificant threats to the stability and well-being of the family system, whichleads parents and teenagers to seek family counseling from health care pro-fessionals.

In the current exploratory study four hypotheses were tested: (1) Fami-lies of disabled adolescents who received single-family, issue-specific therapywill develop a significantly stronger therapeutic alliance than families whoreceived psychoeducational multi-family group therapy; (2) Therapeutic alli-ance will vary across type of family member, with mothers reporting signifi-cantly higher alliance scores than their adolescents; (3) Therapeutic alliancewill remain stable from the third to the sixth session; (4) Therapeutic alliancewill be positively related to improvement of identified family problems.

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METHOD

Inclusionary Criteria

The current study was part of a larger investigation (Glueckauf, 1992) on thedifferential effects of issue-specific vs. psychoeducational counseling for at-risk teens with epilepsy and their parents. Family was defined as a minimumof two family members (the adolescent and at least one parent or guardian).The inclusionary criteria for the study were as follows: The adolescent must(1) have a diagnosis of generalized or partial seizure disorder, (2) be be-tween 12 and 19 years of age, (3) have at least a third-grade reading level, asmeasured by the Monroe Sherman Reading Comprehension subtest (Mon-roe & Sherman, 1966), (4) have at least one parent living in the home, and(5) have significant psychosocial or educational difficulties as determined bya problem checklist. To be included in the study adolescents and/or theirparents must have reported as least one of the following problems: depres-sive affect (e.g., lowered mood that persists for four weeks and interfereswith everyday functioning), poor school performance (i.e., D average orbelow), social withdrawal (i.e., teen spends 75% or more time alone), ag-gressive behavior (i.e., verbally and/or physically assaultive), lack of compli-ance with prescribed medical routines (i.e., teen does not take anticonvul-sant medication at prescribed times 25% or more during the week), sexualpromiscuity, and/or substance abuse. The parent or guardian was requiredto have a minimum of 10 hours of direct contact with the adolescent perweek.

Participants were recruited from a variety of settings across Indiana,including hospitals, schools, and epilepsy support groups. After receivingpreliminary information about the study, and verifying that the family ful-filled the inclusionary criteria, interested families were scheduled for an ini-tial assessment session.

Dropout Analyses

Forty-nine families met the criteria for inclusion into the current study. Twenty-six families withdrew prior to the initial assessment interview. Reasons forwithdrawal included: (1) teen refused to participate (n = 11), (2) too far fromhome (n = 8), (3) too busy (n = 5), (4) family moved from initial location (n= 1), and (5) already in therapy (n = 1). Twenty-three families underwent theinitial assessment interview. Four families dropped out after the initial as-sessment session, and 19 completed all phases of the study. Reasons givenfor dropping out of the study post-assessment included: (1) change in avail-ability (n = 3), and (2) felt therapy was not needed (n = 1). Only two back-ground factors significantly differentiated between post-assessment drop-outs and completers. Adolescents who dropped out post-assessment weresignificantly older (F (1,21) = 18.36, p < .001) than adolescents who com-

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Alliance in Family Therapy for Teens with Epilepsy 129

pleted the study, and mothers who dropped out after the initial assessmentwere significantly less educated (F (1,21) = 5.33, p < .05) than those whocompleted the study.

At the initial assessment session families received further explanationabout the study and procedures, completed consent forms, took the MonroeSherman Reading Comprehension subtest (1966), and completed backgroundinformation forms. Following the initial assessment, adolescents with epi-lepsy and their parents were randomly assigned to attend either multi-familypsychoeducational group therapy or to single family issue-specific counsel-ing (Glueckauf et al., 1992; Long, Glueckauf, & Rasmussen, 1998). Partici-pants in the psychoeducational condition were required to attend five multi-family therapy group sessions, and participants in the issue-specific familycounseling were required to attend five single-family counseling sessions.

Characteristics of Study Completers

Adolescents who completed the study (n = 19) had a mean age of 13.90years (SD = 1.37), and a mean of 8.06 years of education (SD = 1.52). Forty-seven percent of the adolescents were female. The median number of sei-zure episodes reported for the six months preceding the assessment was0.33 seizures per month. Fifty percent of the sample had received priorcounseling, although no participants obtained formal counseling from othersources during the current study. Seventeen of the nineteen families wereWhite and two were African-American; 26% of adolescents had co-occurringconditions, including cerebral palsy, muscle weakness, hearing loss, lazyeye, attention-deficit/hyperactivity disorder, and mild hypoglycemia.

Mothers who completed the study (n = 19) were on average 41 yearsold (SD = 5.13), had a mean of 13.5 years of education (SD = 1.90), and 84%were married. Sixty-three percent were employed, with 52% of those em-ployed working full-time. Five fathers participated in the study. Fathers hada mean age of 45 years. Four of the fathers in this study were employed, andof those employed, all had full-time jobs; one father was retired. All fivefathers were married. The median yearly income for families in this samplewas between $25,000 and $50,000. Note that as a result of low n, data fromfathers were excluded in the statistical analyses.

Procedures

The 19 families who completed all phases of the study were randomly as-signed to either issue-specific family counseling (n = 9) or thepsychoeducational group (n = 10). Therapists who took part in the studywere four graduate students who had a least two years previous counselingexperience, and 128 hours of previous practicum training with teens withdisabilities. Prior to the inception of the project, two of the counselors un-

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derwent a 40-hour training program focusing on the basic principles of theissue-specific family counseling model (IFCM; Long et al., 1998; Glueckauf,1993). The remaining two counselors received 40 hours of training inpsychoeducational family therapy theory and practice (Lewis, Hatton, Salas,Leake, & Chiofalo, 1991; Lewis, Salas, de la Sota, Chiofalo, & Leake, 1990;McFarlane, 1991).

Before the family assessment interview, participants were asked to com-plete two background and medical questionnaires. During the 1.5-hour as-sessment interview, all participants were asked to discuss their specific coun-seling concerns.

For IFCM participants, session two focused on identifying two or threeissues that the adolescent and his/her parent(s) would like to improve (e.g.,difficulties remembering to take epilepsy medication), based on issues gen-erated on initial assessment measures. The counselors proposed tentativeintervention strategies for each of these concerns (e.g., development of asystem to assist with medication management that would work for the spe-cific family). Next, the counselors solicited the adolescents’ and parents’perceptions of the effectiveness and feasibility of each intervention strategy.In sessions three to six, family members were asked to report the progressthey made on each of their goals since the last session, and to identify spe-cific factors that facilitated or hindered goal attainment. Based on these re-ports, the co-therapists either praised their accomplishments or encouragedfurther problem solving. In addition, homework assignments were typicallyprovided at the end of each session and reviewed at the next session.

Families assigned to psychoeducational therapy participated in five 1.5hour multi-family group sessions led by two co-therapists. These groupsfocused on general psychosocial problems, including improving communi-cation among family members, managing anger and frustration, family prob-lem solving, and increasing social assertiveness. A standard educational pro-tocol was used by counselors, which gave a description of how to introducethe topic, the specific activities to perform during the group, questions thatcould be used to generate discussion, homework to be assigned, and con-cluding statements. Although basic information about epilepsy was not em-phasized, families in the psychoeducation condition were encouraged toview videotapes on the medical, pharmacological, and psychosocial aspectsof epilepsy, and to bring any questions about the material to the group. Notethat the mean time of seizure onset was approximately five years prior to thestart of the study. As a result, most families already had acquired basic knowl-edge about epilepsy, its psychosocial impact and medication management.

All participants were asked to complete a modified version of the Work-ing Alliance Inventory (WAI; Horvath & Greenberg, 1989) after sessions threeand six. In addition, they were asked to complete three outcome measures(Glueckauf et al., 1992), including the Issue Severity Scale (ISS), the IssueChange Scale (ICS), and the Issue Frequency Scale (IFS). These measureswill be described below. After completion of the study families received $50as compensation for their participation.

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Alliance in Family Therapy for Teens with Epilepsy 131

Forms and Measures

BACKGROUND FORMS

The Adolescent and Parent Background, Seizure-Related Information, andCurrent Medications Forms (Glueckauf et al., 1992) were developed to as-sess basic demographic, medical, and seizure-related information. In addi-tion, they provided data on previous counseling experiences and familymembers’ goals for treatment.

WORKING ALLIANCE INVENTORY

The Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) is a 36-item scale that measures the quality of the therapist–client working alliancerelationship. The WAI contains three subscales: Goal Agreement, Task Agree-ment, and Bond Development. Goals refer to mutual endorsement by thecounselor and participant on desired therapeutic outcomes. Tasks refer tobehavioral and cognitive processes that occur during counseling sessions.Bond refers to the positive attachment formed between participant and coun-selor (Bordin, 1976). Each subscale contains 12 items. The WAI yields asummed subscale score for each of these components, as well as an overallalliance score. The WAI was chosen for this study because it is not restrictedto a single form of therapy, requires little training to administer, is easy tounderstand (Tichenor & Hill, 1989), and has shown significant positive cor-relations with treatment gains across several therapy orientations (Horvath &Symonds, 1991).

Horvath and Greenberg (1989) reported that the WAI has high internalconsistency (Cronbach’s alpha = .93). Internal consistency coefficients forthe Goal, Task, and Bond subscales were .89, .92, and .92, respectively.Previous psychometric studies (Safran & Wallner, 1991) have shown that theWAI has good convergent validity. The WAI was positively associated withother inventories (e.g., California Psychotherapy Alliance Scales, r = .87, p <.001) designed to measure similar behaviors.

The WAI was modified for use with the population in this study.1 Spe-cifically, the wording of the scale was adjusted to fit the multi-client contextof family therapy. Also, the adolescent form was simplified to ensure that theitem content could be understood at a 3rd grade reading level. In addition,all family members were asked to complete a separate WAI for each thera-pist. A member of the research team who was not directly involved in thetherapy sessions administered the WAI.

OUTCOME MEASURES

Outcome of therapy was assessed using three rating scale measures thattrack change (positive and negative) in the families’ identified issues, as well

1The modified Working Alliance Inventory is available from the first author.

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as changes in the perceived severity and frequency of these issues (Glueckauf,in press; Glueckauf, Picha, & Webb, 1994). The 6-point Issue Severity Scale(ISS) was developed to assess the severity of family problems, with 1 = noproblem, 3 = moderate problem, and 6 = severe problem. The Issue ChangeScale (ICS) was developed to measure the extent of change on identifiedfamily issues with –3 = completely worse to 3 = completely better, with 0indicating no change. The Issue Frequency Scale (IFS) assessed how fre-quently each identified issue occurred. Each score was converted to a monthlyoccurrence rate and recalibrated to a six-point scale. In addition, the ICS,and the ISS and IFS gain scores were combined and summed to form theFamily Therapy Outcome Index (FTOI), a 19-point scale of overall problemimprovement. The internal consistency reliabilities for the FTOI were alsomoderately high. Cronbach’s alpha for this scale was .51 for adolescents, .82for mothers, and .71 for families (mother and adolescent combined).

RESULTS

Psychometric Properties of Modified WAI

The internal consistency reliabilities of the modified WAI were high andconsistent with previous reports. Cronbach’s alpha for the modified WAI was.93 for adolescents and .89 for mothers. Previous WAI studies (e.g., Horvath& Greenberg, 1989) have reported average alphas of .93. Also, the internalconsistency reliabilities for the modified subscales were high. Cronbach’salphas for the modified Goal subscale was .92 for adolescents and .90 formothers; for the modified Task subscale, .93 for adolescents and .95 formothers; and for the modified Bond subscale, .83 for adolescents, and .94for mothers.

Pretreatment Equivalence

To test for pretreatment differences between conditions, chi-squares andone-way ANOVAs were performed on the demographic and medical charac-teristics of both adolescents and their mothers. No significant differenceswere found for adolescents between IFCM and psychoeducational therapygroups for age, education, previous therapy experience, and seizure fre-quency. Similarly, mothers showed no significant variation on age and previ-ous therapy experience across the two groups. However, mothers in theIFCM condition reported significantly fewer (F (1,17) = 5.63, p < .05) years ofeducation (M = 12.56, SD = 5.49) than mothers in the psychoeducation con-dition (M = 14.40, SD = 4.95). Note that this factor did not correlate with theWAI scores or with gains on any of the therapy outcome measures.

No substantial differences in therapist characteristics, including age, race,education, or previous experience, were found between and within treat-

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Alliance in Family Therapy for Teens with Epilepsy 133

ment groups. Because each condition had two co-therapists, we examinedthe variations in the participants’ ratings across individual therapists andwithin conditions. For the two IFCM therapists, average alliance scores were6.02 and 6.00 (t = 1.24, p = n.s.). The average scores for the two multi-familypsychoeducational therapists were 5.85 and 5.80 (t = 1.91, p = n.s.). Therealso were no differences in WAI subscales between individual therapists. Asa result, we used mean therapist scores in the statistical analyses presentedbelow.

Hypothesis Tests

Note that the alpha level for all comparisons was set at p < .05. We purposelydid not correct for compounding Type I error because of the exploratorynature of the current study and small sample size.

HYPOTHESIS 1: DIFFERENCES IN ALLIANCE BETWEEN IFCM AND PSYCHOEDUCATION

We hypothesized that families would differ on overall alliance dependingupon which type of therapy they received: IFCM or psychoeducational fam-ily therapy. Four separate one between (IFCM vs. psychoeducation), twowithin-factor (adolescents vs. mothers; 3rd vs. 6th session) ANOVAs wereperformed on the total WAI and the three WAI subscale scores. Contrary toexpectations, we found no main effect for type of family intervention acrossall WAI measures (average F (1, 17) = 0.63, all ps > .05) (see Table 1 for groupMs and SDs). Although the hypothesized differences in alliance scores wasnot supported for the family unit, individual-level analyses showed that ado-lescents in the IFCM condition reported significantly greater therapeutic alli-ance than adolescents in the psychoeducation condition (F (1,17) = 6.35, p <.05). Thus, adolescents who received issue-specific therapy reported a sig-nificantly more positive relationship with their therapists than their counter-parts in psychoeducational family therapy. No substantial differences in thera-peutic alliance were found for mothers across the two conditions (F (1,17) =1.39, p = n.s.).

HYPOTHESIS 2: DIFFERENCES IN ALLIANCE BETWEEN ADOLESCENTS AND MOTHERS

We predicted that mothers would report significantly higher alliance scoresthan their adolescents. This hypothesis was not supported. Collapsed acrossgroups, mothers’ average total WAI scores were not substantially differentfrom those of the adolescents at session three, session six, or collapsedacross time. However, a significant interaction for family member by group(F (1,17) = 12.17, p < .01) was obtained. Adolescents in issue-specific familycounseling reported significantly stronger therapeutic alliance than their coun-terparts in the psychoeducational condition. In contrast, no differences intotal WAI scores were found for mothers between the IFCM and

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psychoeducational conditions. The same interaction pattern was obtainedacross each of the WAI Bond, Goal, and Task subscales (all ps < .02) (seeTable 1).

HYPOTHESIS 3: DIFFERENCES IN ALLIANCE OVER TIME

We hypothesized that there would be no disparity in overall alliance scoresfor families between sessions three and six. This hypothesis was confirmed.The mean alliance score for families at session three was 5.85 and at sessionsix was 5.84 (t(17) = 0.15, p = n.s.). Subsequent analyses showed that thisrelationship did not change when examined at the individual level. Mothersreported a mean alliance score of 6.06 at the 3rd session, and 6.02 at the 6thsession (t(17) = 0.43, p = n.s.). Adolescents reported a mean alliance score of5.65 at the 3rd session and 5.65 at the 6th session (t(17) = –0.03, p = n.s.).Furthermore, there were no significant differences between the 3rd and 6thsession on any of the WAI subscales.

HYPOTHESIS 4: RELATIONSHIP BETWEEN ALLIANCE AND OUTCOME

We hypothesized that there would be a positive relationship between thera-peutic alliance and positive treatment outcome. This hypothesis was onlypartially supported. On the positive side, adolescents’ therapeutic alliance(e.g., total WAI) was positively correlated with their Family Therapy Out-come Index (FTOI) (r = .44) and this correlation approached statistical sig-nificance (p = .06). Furthermore, four of nine adolescent WAI subscale scoreswere significantly correlated with outcome measures of issue severity and

TABLE 1. Means and SDs of the modified Working Alliance Inventory (WAI)

Taska Bond Goal Total WAI3rd 6th 3rd 6th 3rd 6th 3rd 6th

session session session session session session session session

IFCMb

Ac 5.9(.82) 6.1(.86) 6.2(.36) 6.3(.48) 5.8(.65) 6.0 (.82) 6.0 (.56) 6.1(.67)M 5.9(.55) 5.8(.82) 5.9(.63) 5.9(.75) 5.9(.78) 5.8(.63) 5.9(.63) 5.9(.63)Family 5.9(.62) 6.0 (.56) 6.0 (.39) 6.1(.56) 5.9(.58) 6.0 (.55) 5.9(.56) 6.0 (.55)

Psychoed

A 5.3(.84) 5.1(1.04) 5.6(.83) 5.7(.53) 5.2(.86) 4.9(.93) 5.4(.74) 5.2(.69)M 6.2(.48) 6.3(.44) 6.3(.70) 6.3(.51) 6.2(.59) 6.0 (.47) 6.2(.46) 6.2(.37)Family 5.8(.57) 5.7(.64) 6.0 (.61) 6.0 (.37) 5.7 (.50) 5.4(.57) 5.9(.50) 5.7(.45)

Table Notes: Taska = WAI Task subscale score, Bond = WAI Bond subscale score, Goal = WAI Goalsubscale score. IFCMb = Issue Specific Family Counseling Model. Ac= adolescent scores, M = motherscores. The ns for IFCM and Psychoeducational Family Therapy were 9 and 10, respectively. Therewere no main effects for treatment condition and family member on WAI scores. Also, there were nosignificant differences between the 3rd and 6th sessions on total WAI and on any of the WAI subscalescores. However, we found a significant interaction effect between therapy condition and family mem-ber (F (1,17) = 12.17, p < .01.).

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Alliance in Family Therapy for Teens with Epilepsy 135

change. Adolescent WAI Goal ratings were significantly correlated with theirratings of reductions in issue severity (r = .61, p < .02) and with positive issuechange (r = .49, p = .05). Adolescent WAI Task and Bond ratings were signifi-cantly correlated with positive issue change (r = .49, p = .05 and r = .53, p <.05), respectively.

On the negative side, no significant correlation was found betweenmothers’ total WAI scores and the FTOI (r =.40, p = .11). Only mothers’ WAIGoal ratings were positively associated with reduction of mothers’ ratings ofissue severity (r = .49, p = .05).

DISCUSSION

Four preliminary results were found in this study: (1) There was no signifi-cant difference in the development of the therapeutic alliance for familieswho received single-family, issue-specific therapy compared with those whoreceived psychoeducational multi-family group therapy; (2) The strength ofthe therapeutic alliance is likely to vary as a function of both the type offamily therapy and the specific family member, with teens showing greateralliance in the issue-specific therapy condition compared with teens in themulti-family group therapy; (3) Similar to individual psychotherapy for non-disabled adults, therapeutic alliance in family therapy for teens with epilepsyappears to remain stable from the third to the sixth treatment session; (4)There was a trend for therapeutic alliance to correlate positively with familytherapy outcome for teenagers with epilepsy, but not for their mothers.

First, similar to previous alliance studies, no substantial differences wereobtained between different therapeutic modalities in the current study. How-ever, we found a significant interaction between type of family therapy andfamily member. Adolescents with epilepsy in the IFCM condition reportedsignificantly higher levels of alliance than those in the psychoeducationalgroup, whereas mothers’ levels of alliance did not differ across groups. Onepossible reason for this pattern of findings may lie in the structural differ-ences between the two types of family therapy. IFCM is client-driven, andencourages each family member to establish priorities for intervention andspecific treatment goals. Adolescents had considerable “say” about the ob-jectives of therapy sessions. In contrast, the psychoeducational group fol-lowed a predetermined protocol, thus limiting the family members’ influ-ence on the objectives and course of therapy. Thus, adolescents in the IFCMcondition may have perceived their relationship with the therapist as morepositive than in the psychoeducation groups because they had more free-dom to pursue their individual goals.

Hypothesis 2 focused on the effects of family member type on percep-tions of therapeutic alliance. We hypothesized that mothers would form astronger alliance with the therapists than adolescents. Contrary to prediction,we did not find overall differences between mothers and adolescents in their

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perceptions of therapeutic alliance, but rather an interaction between familymember and type of family therapy. One possible explanation for the com-bined findings of hypotheses 1 and 2 may be located in the fit betweenspecific family therapy approaches and developmental differences betweenmothers and their teens. Adolescents who are actively seeking self-directionand independence may have perceived the behavior of client-centered, IFCMtherapists as more congruent with their developmental needs (e.g., autonomyand independence) than psychoeducational family therapists. IFCM thera-pists encouraged adolescents with epilepsy to actively participate in goalsetting and the direction of therapy, whereas psychoeducational therapistswere required to adhere to predetermined modules, permitting less direc-tion and input from the adolescents. In contrast, mothers showed no sub-stantial differences in family therapy preference. This may be ascribed to thepriorities of the mothers. They may have been more concerned about ob-taining therapy for their adolescents, rather than selecting the “best fit” amongtypes of family therapy and specific therapist style.

Hypothesis 3 addressed the issue of the stability of the therapeutic alli-ance over time. As predicted, therapeutic alliance did not vary between ses-sions three and six. This finding suggested that therapeutic alliance, once itis formed, tends not to change over time. Moreover, alliance was stable fromsessions three to six despite variations in the type of family therapy modalityand family therapy group size.

Perhaps the most intriguing finding in this study involved the relation-ship between alliance and outcome. We found a differential pattern of asso-ciation between adolescents and their mothers for therapeutic alliance andproblem improvement. For adolescents with epilepsy, there was a moder-ately strong trend for therapeutic alliance to covary with reports of problemimprovement. In contrast, mothers’ perceptions of therapeutic alliance wereonly weakly associated with improvement on identified problems.

A possible reason for this finding may lie in the different objectives androles of teens and parents in family therapy. Across all families, treatmentgoals centered on problems associated with adolescents’ psychosocial andeducational functioning (e.g., poor grades, classroom misbehavior) ratherthan the mothers’ personal issues. As a rule, mothers tended to frame therapyas help for their children, rather than as assistance for themselves. Mothersconsequently may have perceived their role as largely supportive and auxil-iary, rather than central to the therapeutic process. Their perceptions of thera-peutic alliance may have been less of a determinant of outcome than fortheir adolescents, who may have been more strongly influenced by sensitiveand supportive therapists.

Although the results of the study should be considered preliminary,they raise two important clinical considerations. First, when conducting fam-ily therapy with a family that has an adolescent with epilepsy, it may bebeneficial to focus efforts on developing a therapeutic alliance with the ado-lescent, rather than parental figures, as therapy outcome seems to be more

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Alliance in Family Therapy for Teens with Epilepsy 137

highly associated with the strength of the adolescent working alliance. Sec-ond, adolescents may respond more positively to tailored approaches tofamily therapy, as opposed to a more structured group presentation of edu-cational materials. Models of family therapy that take into account the priori-ties of adolescents and their need for self-determination may increase thequality of the therapeutic relationship and in turn, heighten the teen’s per-ceptions of the benefits of treatment.

Five major shortcomings of the study are noted. First, the sample sizewas small, and thus, follow-up studies with larger Ns are needed to substan-tiate the validity of the current findings. In addition, the participation rate offathers in our sample was low. Although this finding is consistent with typi-cal levels of paternal participation in therapy and research studies in general(Phares, 1996), it precluded analyses that may have shed light on the devel-opment of working alliance for fathers of teens with disabilities in familytherapy. Second, the generalizability of current findings may be limited to at-risk teens with epilepsy or other episodic, neurological disabilities. Althoughmany of the concerns of adolescents and parents were generic in nature(e.g., grades), it is possible that the results were unique to this medicalpopulation. Third, the current study did not address the therapists’ percep-tions of the effectiveness of the therapeutic modality, or their perceptions ofworking alliance with family members. Fourth, there was no comparisonmade between both treatment modalities and a no-treatment condition. Al-though both modes of therapy appeared to be beneficial, it is difficult todetermine effectiveness without a no-treatment comparison group. Fifth,comparison groups to control for family therapy group size were not em-ployed. It was not possible to determine whether the obtained interactionbetween type of therapy and type of family member was attributable togroup characteristics (e.g., number of participants in the family therapy ses-sion), or developmental differences between adolescents and their mothers.Finally, future research should employ appropriate control groups to teaseout the effect of these factors. Furthermore, follow-up studies with larger Nsare needed to examine differences between parents’ and adolescents’ per-ceptions of the influence of therapist characteristics in the development ofworking alliance and their relationship to therapeutic outcome.

REFERENCES

Austin, J. K. (1989). Comparison of child adaptation to epilepsy and asthma. Journalof Child and Adolescent Psychiatry and Mental Health Nursing, 2, 139–144.

Bordin, E. S. (1976). The generalizability of the psychoanalytic concept of the work-ing alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260.

Glueckauf, R. L. (in press). Family and Disability Assessment System. In J. Touliatos,B. Perlmutter, & M. Straus (Eds.), Handbook of family measurement and tech-niques (2nd Ed.). Newbury Park, CA: Sage.

Glueckauf, R. L. (1992). Examining the links among the problem behaviors of at-risk

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

07:

53 1

9 N

ovem

ber

2014

R. L. Glueckauf et al.138

adolescents with epilepsy, family and community processes, and intervention.National Institute on Disability and Rehabilitation Research, USDE.

Glueckauf, R. L. (1993). Use and misuse of assessment in rehabilitation: Getting backto the basics. In R. L. Glueckauf, L. B. Sechrest, G. R. Bond, & E. McDonel(Eds.), Improving assessment in rehabilitation and health (pp. 135–155). NewburyPark, CA: Sage.

Glueckauf, R. L., Picha, D., & Webb, P. M. (1994). The Family and Disability Assess-ment System Manual. Unpublished manuscript, Indiana University–Purdue Uni-versity at Indianapolis.

Glueckauf, R. L., Webb, P. M., Papandria-Long, M., Rasmussen, J. L., Markand, O., &Farlow, M. (1992). The Family and Disability Assessment System: Consistencyacross judges and measures. Rehabilitation Psychology, 37, 291–304.

Hauser, W. A., & Hesdorffer, D.C. (1990). Epilepsy: Frequency, causes and conse-quences. New York: Demos.

Heatherington, L., & Friedlander, M. L. (1990). Couple and family therapy alliancescales: Empirical considerations. Journal of Marital and Family Therapy, 16,299–306.

Hoare, P. (1984). The development of psychiatric disorder among school childrenwith epilepsy. Developmental Medicine and Child Neurology, 26, 3–24.

Hoare, P., & Kerley, (1991). Psychosocial adjustment of children with chronic epi-lepsy and their families. Developmental Medicine and Child Neurology, 33, 201–215.

Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Work-ing Alliance Inventory. Journal of Counseling Psychology, 36, 223–233.

Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psycho-therapy. Journal of Consulting and Clinical Psychology, 61, 561–573.

Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance andoutcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology,38, 139–149.

Johnson, J., & Alford, R. (1987). The adolescent quest for intimacy: Implications forthe therapeutic alliance. Journal of Social Work and Human Sexuality, 5(2), 55–66.

Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Watkins, J., Elkin, I., & Pilkonis,P. A. (1996). The role of the therapeutic alliance in psychotherapy and pharma-cotherapy outcome: Findings in the National Institute of Mental Health Treat-ment of Depression Collaborative Research Program. Journal of Consulting andClinical Psychology, 64, 532–539.

Lewis, M. A., Hatton, C. L., Salas, I., Leake, B., & Chiofalo, N. (1991). Impact of thechildren’s epilepsy program on parents. Epilepsia, 32, 365–374.

Lewis, M. A., Salas, I., de la Sota, A., Chiofalo, N., & Leake, B. (1990). Randomizedtrial of a program to enhance the competencies of children with epilepsy.Epilepsia, 31, 101–109.

Long, M. P., Glueckauf, R. L., & Rasmussen, J. L. (1998). Developing family counsel-ing interventions for adults with episodic neurological disabilities: Presentingproblems, persons involved, and problem severity. Rehabilitation Psychology,43, 101–117.

Margalit, M., & Heiman, T. (1983). Anxiety and self-dissatisfaction in epileptic chil-dren. International Journal of Social Psychiatry, 19, 220–224.

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

07:

53 1

9 N

ovem

ber

2014

Alliance in Family Therapy for Teens with Epilepsy 139

Matthews, W. S., Barabas, G., & Ferrari, M. (1982). Emotional concomitants of child-hood epilepsy. Epilepsia, 13, 671–681.

McFarlene, W. R. (1991). Family psychoeducational treatment. In A. S. Gurman &D. P. Kniskern (Eds.), Handbook of family therapy (Vol. 2) (pp. 363–395). NewYork: Brunner/Mazel.

Monroe, M., & Sherman, E. E. (1966). Monroe-Sherman Group Diagnostic ReadingAptitude and Achievement Test. H. Neurins Printing Company.

O’Malley, F. (1990). Developing a therapeutic alliance in the hospital treatment ofdisturbed adolescents. Bulletin of the Menninger Clinic, 54, 13–23.

Phares, V. (1996). Conducting nonsexist research, prevention, and treatment withfathers and mothers: A call for change. Psychology of Women Quarterly, 20, 55–77.

Pinsoff, W. M., & Catherall, D. R. (1986). The integrative psychotherapy alliance:Family, couple and individual therapy scales. Journal of Marital and FamilyTherapy, 12, 137–151.

Rae, W. A. (1992). Common adolescent-parent problems. In C. E. Walker, & M. C.Roberts (Eds.), Handbook of Clinical Child Psychology (2nd Ed.) (pp. 555–564).New York: John Wiley & Sons, Inc.

Ryan, E. R., & Cicchetti, D. V. (1985). Predicting quality of alliance in the initialpsychotherapy interview. The Journal of Nervous and Mental Disease, 173, 717–725.

Safran, J. D., & Wallner, L. K. (1991). The relative predictive validity of two therapeu-tic alliance measures in cognitive therapy. Psychosocial Assessment: A Journalof Consulting and Clinical Psychology, 3, 188–195.

Scott, D. J. (1978). Psychiatric aspects of epilepsy. British Journal of Psychiatry, 132,417–430.

Tichenor, V., & Hill, C. (1989). A comparison of six measures of working alliance.Psychotherapy, 26, 195–199.

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

07:

53 1

9 N

ovem

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