Parent-adolescent alliances as a predictor of retention in functional family therapy

This study examined adolescent?mother and mother?adolescent alliances and their relationship with treatment retention in Functional Family Therapy (FFT). Participants were 58 families selected from a larger sample of 240 single mothers and their delinquent adolescents. The families were classified either as treatment completers (N= 29) or dropouts (N=29). Archived videos of first and second FFT sessions were rated in 20-minute segments using the Parent-Adolescent Alliance Rating System for Therapeutic Settings to determine the nature of parent-adolescent and adolescent-parent alliances as they progressed through early treatment. As hypothesized, completer families demonstrated an increase in alliance scores from the middle to the end of second sessions while dropout families did not. Results also indicated that completer families scored significantly higher than dropout families beginning at the middle of the first session, and remaining so across all segments measured. These findings highlight the importance of parent-child relationships and how they are expressed and evolve or fail to evolve during early therapy sessions.

FAMILY PARENT-ADOLESCENT ALLIANCES AS A PREDICTOR OF RETENTION IN FUNCTIONAL F AMIL Y THERAPY by Malinda J. Freitag A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science Department of Psychology The University of Utah May 2010 Copyright © Malinda J. Freitag 2010 All Rights Reserved The G r a d u a t e School THE UNIVERSITY O F UTAH S U P E R V I S O R Y C O M M I T T E E A P P R O V A L of a thesis submitted by Malinda Freitag This thesis has been read by each member of the following supervisory committee and by a majority vote has been found to be satisfactory. The Graduate School THE UNIVERSITY OF UTAH SUPERVISORY COMMITTEE APPROVAL J. satisfactory. Date Date Date nald Strassberg The G r a d u a t e School THE UNIVERSITY O F UTAH F I N A L R E A D I N G A P P R O V A L To the Graduate Council of the University of Utah: I have read the thesis of Malinda J. 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Approved for the Graduate Council ~'V ' Dean of The Graduate School A. 1- adolescent-•mother mother-^adolescent their relationship with treatment retention in Functional Family Therapy (FFT). Participants were 58 families selected from a larger sample of 240 single mothers and their delinquent adolescents. The families were classified either as treatment completers (N= 29) or dropouts (N=29). Archived videos of first and second FFT sessions were rated in 20-minute segments using the Parent-Adolescent Alliance Rating System for Therapeutic Settings to determine the nature of parent-adolescent and adolescent-parent alliances as they progressed through early treatment. As hypothesized, completer families demonstrated an increase in alliance scores from the middle to the end of second sessions while dropout families did not. Results also indicated that completer families scored significantly higher than dropout families beginning at the middle of the first session, and remaining so across all segments measured. These findings highlight the importance of parent-child relationships and how they are expressed and evolve or fail to evolve during early therapy sessions. ABSTRACT This study examined adolescent-mother and mother-adolescent alliances and of240 N = N = 29). adolescent-families importance of parent-child relationships and how they are expressed and evolve or fail to evolve during early therapy sessions. Single-Parent Households 10 METHOD 13 Participants 13 Parent-Adolescent Alliance Rating Scale for Therapeutic Settings 14 Procedure 15 RESULTS 18 Evaluation of Interrater Reliability for the PAARS 18 Analysis of the Primary Hypothesis 18 Analyses of the Factor Analyses 21 DISCUSSION 24 Limitations 27 Clinical Implications 28 Appendices A: PARENT-ADOLESCENT ALLIANCE RATING SCALE FOR THERAPEUTIC SETTINGS 29 34 TABLE OF CONTENTS ABSTRACT ....... . ... ........ .. ..... .. ..... .. ....... .. ... . ......... . .. ........ . ........... ............ iv INTRODUCTION . .... .. ............................................. . ....... . .... .. .. ........... .. 1 Risk Factors for Delinquency and Treatment Implications .. . ... . ............ ........ 3 Bonding and Family Relationships .... . .................................... .. ......... .. 6 Single-Parent Households . .. . ......... . ..... . . . .... ... .............. . . .... ... .. ...... . .. . 10 METHOD ... . .............. . ........................ . ............ . .......... . .... .............. ...... 13 Participants ......... . ........... . .. ......................... . .......... . .... .. ... .... ... .. .. 13 Parent-Adolescent Alliance Rating Scale for Therapeutic Settings ............ ..... 14 Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15 RESULTS ................... . ........ . ........... . ....... . ............ . ............ ...... .. .... ..... 18 Evaluation of Interrater Reliability for the P AARS ................ ... ......... ...... 18 Analysis ofthe Primary Hypothesis ................ . ..... .... ..... . . . ....... ..... ... .... 18 Analyses ofthe Factor Analyses ...................................... .... .. ........ .... 21 DISCUSSION .. . .. ...... .. ... ... ... ... . .. . .. . .. . .. . .. .... .. ... .... ... ...... ... . .. ... .. ............ 24 Limitations ................................................................. .... ..... .. .. ... 27 Clinical Implications ............................................................. .. . .. . .. 28 Appendices A: PARENT-ADOLESCENT ALLIANCE RATING SCALE FOR THERAPEUTIC SETTINGS ...................................................................... ... .. ... ... ... ...... 29 B: FACTOR ITEMS AND FACTOR LOADINGS .. .... .................... . ......... .. ... ....... 32 REFERENCES ........... .. ........ . ....................... . ..... . .... . ........ .............. .. ... 34 & & Maclver, 1993; Smetana, 1988, 1989, 2000). Parent-child relationships have often been examined in terms of risk/protective factors for delinquent behaviors (Conger, Lorenz, Elder, Melby, Simons, & Conger, 1991; Dishion, Patterson, Stoolmiller, & Skinner 1991; Ge, Best, Conger, & Simons, 1996; Gorman-Smith, Tolan, Zelli, & Huesmann, 1998; Gutman, McLoyd, & Tokoyawa, 2005; Gutman & Eccles, 2007; Hawkins, Catalano, & Miller, 1992; Henry, Tolan, & Gorman-Smith, 2001). Some clinical research has also studied changes in family functioning as a result of therapy (Alexander, Pugh, & Parsons, 1998; Parsons & Alexander, 1973; Sexton & Alexander, 2002). However, in the context of family treatment for delinquent adolescents, little research has been conducted on actual in-session family relationship processes present in family therapy. The little research that has been done has focused primarily on therapist techniques and on the therapeutic alliance patterns (i.e., between family members and the therapist) and the relationship between these therapist focused domains and treatment outcome (Diamond, Liddle, Hogue, & Dakof, 1999; Hogue, Dauber, Stambaugh, Cecero, & Liddle, 2006; Robbins, Turner, Alexander, & Perez, 2003; Robbins, Liddle, Turner, Dakof, Alexander, & Kogan, 2006). INTRODUCTION Adolescence is a stressful period for parent-child relationships (Buchanan, Eccles, Becker, 1992; Eccles, Midgley, Wigfield, Buchanan, Reuman, Flanagan, MacIver, 1989,2000). ofriskiprotective Diamond, & & Robbins, Turner, Alexander, & Perez, 2003; Robbins, Liddle, Turner, Dakof, Alexander, & Kogan, 2006). emerge during family therapy sessions. The absence of such information is surprising given the assumption that changes in family relationships during therapy for delinquent behaviors are significant predictors of youth outcome (Alexander et al., 1998; Sexton & Alexander, 2002). these relationships as they relate to treatment outcome. This study represents a unique application of the alliance construct in that it examined a particular aspect of within-family functioning in the therapy context. Family alliance was defined as a representation of one person's expressed experience and behavior in this particular, transactional relationship in the context of therapy. While this study assumed that the expression was representative of the person's experience it is important to note that the expression was measured by external raters rather than representing an individual's internal experience. outcomes. However, the focus on therapist technique and alliance fails to capture the established family relationships patterns and possible changes in these patterns as they aI., The proposed study aimed to examine parent-adolescent alliances in early Functional Family Therapy (FFT) sessions in order to gain a greater understanding of within­family 2 Based on numerous studies of family risk and protective factors for delinquency (referenced below), it was posited that an already delinquent adolescent population would enter into treatment with maladaptive parent-child relationship or bonding patterns, and that a positive change in these relationships would be related to positive treatment Implications and reflected in reductions in negativity and blame), the manualized FFT protocol (Alexander et al., 1998, 2000,) prescribes specific interventions that produce positive changes in within-family alliance. Furthermore, this emphasis is primary during the engagement and motivation phase, which constitutes the first few sessions of intervention. In turn, early session improvements in within-family alliance are linked to the proximal outcomes of retention versus dropout in therapy (Robbins et al., 2003), which represented the main outcome variable of this study. In fact, the relationships between family members represent the variables that therapists are instructed to use to determine whether a shift towards the next phase of treatment is warranted (Alexander, 2009). decreased negativity and blame, increased family bonding, and a balanced alliance between family members and the therapist. However, a direct test of this important FFT hypothesis has yet to be conducted. Therefore, the primary aim of this study was to 3 Risk Factors for Delinquency and Treatment Implications This study involved Functional Family Therapy (FFT), which has been independently identified as an evidence-based treatment for dysfunctional youth (U.S. Surgeon General's Report, U.S. Department of Health and Human Services, 2001; Elliot, 1997). With respect to specific within-family alliance (identified as "family bonding") aI., tum, aI., 2009). FFT posits that therapist change meaning techniques (i.e., specific words and phrases that are designed to change the attributional and emotional tags that are tied to an event/situation) and change focus techniques (i.e., changing the way content is presented in order to interrupt or divert a subject in a strength-based, relational way) leads to al., process. For example, in a particular session that includes a therapist, mother, and adolescent, six alliance patterns are present: adolescent-^therapist, mother-^therapist, adolescent-smother, mother-^adolescent, therapist-^adolescent, and therapist->mother. All are seen as important (though the latter two often under different labels) in the treatment literature. Such multiple relationship phenomena are not present in individual psychotherapy. In individual psychotherapy, the client-therapist alliance is often seen as the primary predictor of outcome (it is ubiquitous). In family therapy the phenomenon is replicated in terms of family members' and therapist alliance, but in FFT Robbins et al. (2003) found that the balance of the alliance between individual family members and the therapist was important not the absolute amounts. Since FFT works directly on the relationships of family members with each other during the initial phase of therapy, the model states that positive changes in these relationships predict retention. However, that direct link between family alliance and outcome has not been tested. al., al., al., examine the trajectory of parent-adolescent and adolescent-parent alliances across the first two sessions of FFT. 4 Previous research has shown that in individual psychotherapy, therapeutic alliance is a "consistent predictor of outcome" (Robbins et aI., 2003, 2006, 2008). However, this relationship between alliance and outcome in individual therapy does not necessarily translate to the family therapy context. In fact, family therapy presents a unique circumstance for all the individuals present and for researchers trying to understand the adolescent~therapist, mother~therapist, adolescent~mother, mother~adolescent, therapist~adolescent, therapist~mother. aI. model states that positive changes in these relationships predict retention. However, that direct link between family alliance and outcome has not been tested. A small number of studies have examined therapeutic alliance (i.e., the alliance between family members and the therapist) as a predictor of treatment outcome in families (Diamond et aI., 1999; Hogue et aI., 2006; Robbins et aI., 2006), but they have adolescent-therapist (2006) found that higher parent-therapist alliance and improvement in adolescent-therapist alliance by midtreatment across sessions predicted positive outcome. Also studying MDFT, Robbins et al. (2006) found that families who failed to complete treatment demonstrated a significant decline from session 1 to 2 in overall family alliance with the therapist. family alliance in family therapy by adding these parent-adolescent alliances into the research focus, reflecting its centrality in the family treatment literature. In family therapy, it is very important for therapists to recognize and address maladaptive relationship patterns between family members. This is a particular emphasis of FFT and other family-based intervention models based on multiple reviews (U.S. Surgeon General's Report, U.S. Department of Health and Human Services, 2001; NIH Publication 02-4212, 2001) suggesting that family bonding and conflict represent major risk/protective factors in adolescent drug use and delinquency treatment. study's 5 produced inconsistent results, perhaps due to the specific intervention models studied. For example, with respect to outcomes, Hogue et al. (2006) found that higher early adolescent~therapist alliance predicted, paradoxically, higher externalizing behavior outcomes in Multi-Dimensional Family Therapy (MDFT). Additionally, Hogue et al. adolescent­therapist While these certainly point to the importance of therapeutic alliances in family therapy, previous research has not examined another presumably critical relationship present in family therapy sessions: the parent-child alliance, or the therapeutic relationship between parent and child. This study proposed to further the examination of family-This study'S primary aim was to examine the relationship of the alliances between parent and delinquent adolescent and therapy retention (drop versus complete). Parent- (parent-^adolescent) (adolescent-^-parent). Relationships developmental goals during adolescence is to establish personal autonomy (Eccles et al., 1993; Erikson, 1959; Smetana, 2000; Steinberg, 1990), this can lead to a disruption in parental relationships centered on issues of parental control versus adolescent autonomy (Gutman & Eccles, 2007). As adolescents attempt to establish their own autonomous identity, they may begin to question their parents' control and struggle for more decision­making power (Smetana, 1988, 1989, 2000). In response to these and other developmental changes in their adolescents, parents often become fearful for their adolescents' safety and might restrict the amount of autonomous decision-making opportunities for their teens (Eccles et al., 1993; Eccles, Lord, & Roeser, 1996). This strain in parental relationships is expected to be seen in early adolescence and continue throughout this developmental period (Montemayer, 1983). 6 adolescent alliances were rated according to the behaviors, affect, and relational (or nonrelational) language the parent and adolescent exhibited towards each other during therapy. It is important to note that treatment models usually expect some degree of reciprocity between parent-adolescent and adolescent-parent alliances consistent with the above reviewed literature. However, there can be, and often are, important differences in the level of alliance from parent to adolescent parent~adolescent) and adolescent to parent (adolescent~parent). Bonding and Family Relationships Adolescence is a turbulent time in which familial relationships can be tested and family members often experience strife with each other. While one of the most important aI., decision-aI., al. academic achievement, self-concept, mental health, delinquency, and substance abuse (Gutman & Sameroff, 2004; Herman, Dornbusch, Herron, & Herting, 1998; Holmbeck & O'Donnell, 1991). & & conflict between parents and adolescents which could lead to increased problems found in adolescence such as delinquency and substance abuse (Gutman & Eccles, 2007). Many studies have found evidence that family conflict and hostile parenting practices increase delinquency in adolescence while parental warmth and involvement predict lower rates of both delinquency and depression in adolescents (Chassin, Pillow, Curran, Molina, & Barrera, 1993; Ge et al., 1996; Patterson, Reid, & Dishion, 1992; Scaramella, Conger, & Simons, 1999; Simons, Wu, Conger, & Lorenz, 1994). family 7 Research has also noted positive adolescent outcomes in relation to familial relationships. Eccles et aI. (1996), Lord, Eccles, and McCarthy (1994), and Yee and Flanagan (1985) all found positive relationships between self-esteem and psychological adjustment and adolescents' participation in family decision making. Similarly, several studies have found long-term positive effects of adolescent family decision-making on Additional difficulties with parental relationships might center on a disconnect between an adolescent's desire to be autonomous while at the same time needing more emotional closeness and open communication with their parents (Gutman Eccles, 2007). During this confusing period, parents might respond by withdrawing emotionally from their adolescents or displaying more hostility in an attempt to thwart problem behavior (Gutman Eccles, 2007). These family patterns often lead to an increase in the found aI., Gutman and Eccles (2007) examined the effects on adolescent outcomes of family relations from early through late adolescence. They defined family relations in both would have less depression, higher self-esteem, and fewer problems with delinquent behavior. While examining the relationship between negative parenting and delinquency the authors found that negative family relations were positively related to delinquency and that negative interactions had both concurrent and longitudinal effects on both delinquency and mental health. The authors suggested that these findings represent transactional processes between adolescent outcomes and negative family interactions (i.e., an adolescent who experiences family negativity might engage in delinquent behavior which in turn, increases negative interactions in the family which increases the adolescent's delinquent behavior). Other studies have also suggested that family variables such as monitoring (Dishion et al., 1991), family relationship characteristics (Gorman-Smith et al., 1996), and parenting characteristics and patterns of family relationships (Gorman-Smith et al., 1998) all directly affect adolescent behavior and delinquency involvement. found expectations for behavior, few and inconsistent rewards for positive behavior, severe and inconsistent punishment for poor behavior, and poor parental monitoring have also all 8 negative (adolescents' perceptions of negative family interactions) and positive (adolescents' positive identification with their parents) domains. The authors hypothesized that adolescents who perceived fewer negative family interactions, an increased role in decision-making, and greater positive identification with their parents family family relationships (Gorman-Smith et al., 1998) all directly affect adolescent behavior and delinquency involvement. In studying the effects of family relationships and parenting on delinquency, many different aspects of the family have been implicated. Conger et al. (1991) found that consistent and high family conflict and parental rejection and disengagement are related to adolescent substance abuse and other antisocial behaviors. Unclear 1992). found partially mediated by peer violence and delinquency. Specifically, a lower likelihood of both affiliation with violent peers and individual violence and delinquency was found in families characterized by effective parenting and warm interpersonal relationships while an increased level of violent behavior was found in families characterized by ineffective parenting and low emotional closeness coupled with high levels of deviant beliefs. Similarly, Gorman-Smith, Tolan, Henry, and Florsheim (2000) examined family effects on delinquency in economically disadvantaged inner-city African American and Mexican American male adolescents. After controlling for socioeconomic status, youth in both groups from exceptionally well functioning families demonstrated significantly better functioning across outcomes such as involvement in positive activities, educational aspirations, and both internalizing and externalizing symptoms while youth from struggling families showed worse outcomes. & have a negative impact on the strength of their alliance with their parents. In light of 9 been found to increase the risk for delinquency in adolescents (Hawkins, Catalano, & Miller, 1992). Henry, Tolan, and Gorman-Smith (2001) found that both violent and nonviolent delinquency were predicted by family characteristics. The authors also found that these direct effects of family characteristics on delinquency remain despite being ineffective effects from Considering the broader research on risk and protective family factors for adolescent delinquency, it was expected that the participants in this study would enter into therapy with maladaptive family relationship patterns. In addition, previous research also has shown that adolescents tend to verbalize less than their parents in therapy sessions, apparently due to the blaming and criticism they tend to receive from their parent(s) and from other authority figures (Mas, Alexander, Barton, 1985). This would 10 Single-Parent Households been associated with negative outcomes for children and adolescents including problem behaviors, scholastic and employment difficulties, and psychiatric disturbances (Demo & Acock, 1996; McLanahan, 1997, 1999; McLanahan & Sandefur, 1994). Several studies have also found that children and adolescents are more likely to engage in delinquent and antisocial behaviors if they come from a single parent household than those who come from intact families (Barber & Eccles, 1992; Dornbusch, Carlsmith, Bushwall, Ritter, Leiderman, Hastorf, & Gross, 1985; Kalter, Riemer, Brickman, & Chen, 1985; Peterson & Zill, 1983; Zill, 1978). Unfortunately, the highest rate of single-parent families is found in economically disadvantaged families (Duncan, 1994; Liaw & Brooks-Gunn, 1994; McLoyd, 1998), which increases the risk of delinquency as low socioeconomic status has also been long implicated in the development and maintenance of deviant behaviors in children and adolescents (Bursik & Grasmick, 1993; Loeber & Wikstrom, these considerations it was posited that a change in these maladaptive patterns during therapy would be related to completion of treatment versus dropout. Specifically, it was hypothesized that families who complete therapy will have demonstrated a greater improvement in parent-adolescent alliance patterns during early sessions than those families who fail to complete therapy. Parent Households Considering that single-parent families are such a vulnerable group and are at "-, increased risk for adolescent delinquency, the present study focused solely on single mothers and their delinquent adolescents in family therapy. Single parenting has long socioeconomic & & & parent-child relationships of 10t h-grade adolescents in the context of single families by gathering data on both parent and child perceptions of the relationship via questionnaires and interviews and also by observing parents and children in a discussion session. They found that single-parent families exhibited higher levels of conflict than intact families, both in terms of perceptions and observations of verbal interactions between parent and child. They also found that, in single-parent families, both parents and children exhibited a clear pattern of less adequate ego-functioning and were less tolerant of ambiguity and dissonance, showed less objectivity in their problem-solving, were less playful and empathic, and were more likely to exhibit non-age-appropriate behaviors and make negative attributions about others than members of intact families. These results replicated other research findings (Cohen, 1994; Hetherington et al., 1989) that suggested single-parent families tend to experience more conflict and less cohesion than intact families. conflict (adolescent-^parent, parent-^adolescent) 1993; Stouthamer-Loeber, Loeber, Wei, Farrington, & Wikstrom, 2002; Wikstrom & Loeber, 2000). 11 Previous research on single-parent families has found that children are at increased risk for both externalizing and internalizing behavior problems and lower levels of both cognitive and social competence (Hetherington & Clingempeel, 1992; Hetherington, Stanley-Hagan, Anderson, 1989). Walker and Hennig (1997) examined 10th-aI., single-parent families tend to experience more conflict and less cohesion than intact families. Based on the previously reviewed literature on parent-child bonding and conflict and its relation to delinquency, it was expected that the alliances between the adolescent and parent adolescent~parent, parent~adolescent) would be weak at the outset of therapy (i.e., session 1). However, the proposed study hypothesized that families who completed treatment would show a positive slope of alliance across four segments of sessions 1 and 2, while families who had dropped out of treatment would not show an increase in these alliances across segments. 12 Participants of 240 (N= 4 8% (N= and 52% of the adolescents were White ( N = 30), 2 4% Latino (JV= 14), 16% African- American (N= 9), 0.03% American Indian (N= 2), and 0.05% Other (N= 3). Single mother families were selected from the archives of a clinical study investigating the relationship in FFT between specific therapeutic processes and outcomes. The larger sample consisted of multiethnic youth that represent a cross section of adolescents in the Las Vegas juvenile justice system from the time at which the sample was gathered (Burke, 2003). This larger sample consisted of adolescents with multiple problems including conduct and behavior problems (80%), drug related crimes (70%), and violence (40%). All the adolescents were referred by the juvenile justice system in Nevada for substance abuse-related, status, or violent offenses. It is important to note that this study is retrospective in nature. 2003, 2006). METHOD Participants for this study were single-mother families selected from a larger sample of240 families (180 Completer families and 60 Dropout families). Participants were 58 delinquent adolescents and their single mothers who received FFT treatment. Of this sample, 52% of the adolescents were female N = 30) and 48% were male N = 28), ofthe = 24% N = African­American 2), For the total pool of subjects, families were classified into one of two groups, Dropouts and Completers, using the same criterion as Robbins et al. (2003,2006). al., al. 2003, 2006, Adolescent Settings al., Parent- Adolescent Alliance Rating Scale for Therapeutic Settings (PAARS) consisted of 25 items and was intended to capture the strength of alliance between individual family members and a cohort family member. The PAARS system was developed by the investigator of this study to examine adolescent-parent relationships in the family intervention context. Ratings were based on observations of family members' behaviors and adolescent-parent interactions as they occurred in the sessions. Each item was rated "':, 14 Specifically, two conditions had to be met for a case to be classified as a Dropout. First, the family had to have attended fewer than eight sessions and be designated by the therapist as having dropped out of treatment before the therapist considered them to have successfully completed the three major phases of FFT (Alexander et. aI., 1997). According to Robbins et aI. (2003,2006, 2008), this minimum criterion of 8 sessions was selected based on extensive discussions among leading family therapy model developers and researchers who concurred that 8 sessions represented a minimum necessary dose of family therapy. Second, the FFT therapist treating the family had to have identified the case as a Dropout. Completer cases also had to have met two criteria. First, they had to have attended eight or more sessions, and second, they had to be categorized by their treating FFT therapist as an appropriate, scheduled termination. Only cases that met both criteria for either group were included in this study. Parent-Adolescent Alliance Rating Scale for Therapeutic Settings Based on the Vanderbilt Therapeutic Alliance Scale-Revised (VTAS-R), which was used to successfully discriminate in-session processes between therapists and clients in Dropouts versus Completers in prior research (Robbins et aI., 2003, 2006), the Parent­Adolescent P AARS) P AARS internal consistency, and convergent validity (Hartley & Strupp, 1983; Kamin, Garske, Sawyer, & Rawson, 1993; Krupnick, Sotsky, Simmens, Moyer, Elkin, Watkins, & Pilkonis, 1996). Analysis of the VTAS-R also indicated strong interrater agreement (ICC(i;ii) = .80) and internal consistency of .95 (Diamond et al., 1999). A pilot study (N = 28) on the PAARS conducted by the investigator of the present study found both adequate interrater reliability (mean 82.2% agreement within one scale point on the Likert scale 0-5). A factor analysis of the PAARS pilot data revealed two main factors: a positive working alliance and a hostile or avoidant pattern which replicated the factor structure of the VTAS-R (Robbins et al., 2003). Based on these pilot data findings, the PAARS appeared to be a reliable measure of parent-child alliances. In addition to these findings, the PAARS was also reviewed by three of the authors on the Robbins et al. study (one of whom is also the FFT model developer) who felt that the system would provide a valid representation of the parent-adolescent alliance. Procedure al. 2003, 2006, 2008) al. (2003, 2006, 2008) investigations, clinical sessions 1 and 2 were rated. Using the 15 on a Likert-type scale ranging from 0 (not at all) to 5 (a great deal). The original VTAS, from which the VTAS-R was developed, has demonstrated adequate interrater reliability, (ICC(l,]]) = aI., (P AARS P AARS factor aI., P AARS ai. provide a valid representation of the parent-adolescent alliance. Selection of Sessions and Segments In their study, Robbins et ai. (2003,2006,2008) focused on early sessions that are believed to be "critical" since FFT is based on the premise that if family members experience little or no alliance during early sessions, they are at increased risk for dropping out of treatment. Since this study represented an extension of the Robbins et ai. 2003,2006,2008) al., Parent-adolescent 1-1-served as the reliability rater. Training involved biweekly training meetings for 2 years during which raters were required to learn the definitions and decision rules provided in the Parent-Adolescent Alliance Rating Scale Rating Manual. Raters were trained to criterion with videotapes of therapy sessions that were not included in this study. Raters were required to achieve a minimum acceptable 80% exact agreement reliability before commencing study ratings. The rater who represented the final reliability rater was the one who achieved the most rapid attainment of overall criterion, and who also maintained the highest level of reliability throughout the entire training period. adolescent-^-parent-^alliance (e.g., the parent's willingness to listen to their adolescent, blame their adolescent, or take responsibility for the problems with their adolescent). approach of Robbins et aI., each session was divided into 20-minute segments. Parent­adolescent alliances were rated across four segments total: session I-segment 1, session I-segment 2, session 2-segment 1, and session 2-segment 2. Selection and Training of Raters 16 The primary rater was a graduate student enrolled in the doctorate program of clinical psychology at the University of Utah. While several additional potential raters were also trained, only one undergraduate student enrolled in the bachelor's program Two ratings were generated for each session, one for the adolescent---+parent alliance (e.g., the adolescent's willingness to listen to their parent, blame their parent, or take responsibility for the problems with their parent) and one for the parent---+adolescent In order to establish units of rating that were comparable across families, the videos of sessions 1 and 2 for each family were divided into two 20-minute segments. 17 individual ratings to the parent (for the parent to adolescent alliance) and adolescent (for the adolescent to parent alliance), then repeating this procedure for the second 20 minutes of the video, resulting in four total segments for each participant. Note: The design and analytic strategy for this study was implemented to be consistent with FFT's phase based approach. This study implemented a design centered on segments rather than sessions, which was consistent with FFT theory's description of the engagement and motivation phase of treatment. According to FFT theory, the first two sessions of treatment are included in this phase which is predictive of retention rather than the individual sessions themselves. This study chose to focus on the four segments of time across sessions in order to better describe this early phase of treatment according to FFT theory. Ratings consisted of watching the first 20 minutes of a video, stopping it, and assigning PAARS 31(PAARS a biostatistician who has worked with FFT research for over 30 years (Dr. Charles Turner), who independently found the Kappa to = .94. Hypothesis Segment) segment. These adolescent and mother scores for Segments 1 -4 served as the alliance dependent variable (see Table 1 and Figure 1). RESULTS Evaluation of Interrater Reliability for the P AARS Interrater reliability was evaluated on a total of 62 segments from 31 (15 completer families, 16 dropout families) sessions that were rated by both raters. Raters achieved 89.68% exact agreement across all the comparisons. This evaluation replicated the findings of Robbins et al. (2003, 2006) reliability findings using the VTAS-R which further supported the reliability of the P AARS measure. In addition, the data were sent to = Analysis of the Primary Hypothesis To test the primary hypothesis, a 2 (Retention Status) x 2 (Role) x 4 (Segment) repeated measures analysis of variance was performed. Retention status (drop, complete) served as the between-subjects factor while family role (mother, adolescent) and segment (1-4) served as within-subjects factors. An average alliance score, consisting of the average of all 25 items' individual scores, was computed for each family member at each 1-4 served as the alliance and Factor Scores x Retention Status, Family Role, and Therapy Segment Se^ jrnent 1 Sej Dropouts (n = 29) mient 2 Segment 3 Set mient 4 Family Role M SD M SD M SD M SD Parent 2.48 .56 2.54 .53 2.54 .58 2.39 .56 (Total Score) Adolescent 2.03 .75 2.05 .80 1.98 .85 1.89 .86 (Total Score) Parent 1.94 .79 1.99 .70 1.99 .77 1.84 .76 (Factor 1) Adolescent 1.39 .98 1.47 1.07 1.40 1.07 1.36 1.12 (Factor 1) Parent 3.32 .54 3.41 .54 3.32 .49 3.15 .61 (Factor 2) Adolescent 2.72 .80 2.76 .78 2.68 .86 2.47 .94 (Factor 2) Completers (n = 29) Sej *ment 1 mient 2 Segment 3 Se{ »ment 4 Family Role M SD M SD M SD M SD Parent 2.82 .52 2.85 .58 2.84 .46 3.11 .54 (Total Score) Adolescent 2.40 .57 2.57 .60 2.44 .54 2.74 .63 (Total Score) Parent 2.36 .64 2.41 .81 2.46 .64 2.82 .79 (Factor 1) Adolescent 1.83 .76 2.07 .81 1.88 .76 2.35 .92 (Factor 1) Parent 3.44 .80 3.53 .81 3.54 .64 3.74 .54 (Factor 2) Adolescent 3.04 .58 3.08 .78 3.05 .55 3.28 .67 (Factor 2) 19 Table 1 Means and Standard Deviations of Family Alliance Total Scores, Factor 1 Scores, and 2 Segment Segment Segment 2 Segment 3 Segment 4 M M M 2048 .58 .56 .80 1.89 .79 .77 1.84 1047 lAO 1.07 3041 .54 3.32 049 2.72 2047 Com pieters Segment Segment Segment M M M 2.84 046 2040 2044 .54 .64 2041 .81 2046 2.82 .79 Adolescent .76 2.07 .81 1.88 3044 3.54 .64 3.74 .54 3.08 3.28 Mean Alliance for Total PAARS Scores F(\, = (M= SD = F(l, = 9.30,p < alliance between segments for drop versus completer adolescents and for drop versus completer mothers, a series of paired samples /-tests was performed. This was done by pairing Session 1-Segment 1 with Session 1-Segment 2, Session 1-Segment 2 with 20 3.5 3 2.5 2 -- ....... - - - • RAComp 1.5 1 0.5 0 1-1 1-2 Figure 1 P AARS Scores ... - ..... 2-1 2-2 - .... RADrop • MomComp - •• Mom Drop The analyses found a statistically significant main effect for family role F(I, 56) = 64.71, p < .001 with mothers (M= 2.70, SD = 0.54) showing significantly higher mean alliances than adolescents 2.26, = 0.70). Results also demonstrated a statistically significant Segment x Retention Status effect that was consistent with this study's hypothesis, 1, 56) = .001. In order to demonstrate the changes in t-I-I-I-determine scores from segment 3 to segment 4 (t -3.895,p .001) with no significant changes between any of the other segments. Dropout adolescents demonstrated no significant change in alliance across segments. Completer mothers demonstrated the same general pattern of alliance as their adolescents with a significant increase in alliance scores from segment 3 to segment 4 (t -4.123,/? < .001). Dropout mothers demonstrated a significant decrease in alliance from Session segment 3 to segment 4 (t = 3.172,/? < .01). ANOVAs between-significantly of the Analyses PAARS 21 Session 2-Segment 1, and Session 2-Segment 1 with Session 2-Segment 2 for adolescents and mothers in both conditions. In order to address the problem of multiple comparisons a Bonferroni correction of a/3 was used to obtain an adjusted a = .016 to determine significance. Completer adolescents demonstrated a significant increase in alliance = = significant from = 4.123,p = 3.172, p Additionally, eight simple one-way ANOV As were conducted on a per-segment basis for both mothers and adolescents with Retention Status as the between-subjects factor. Completer participants (both mothers and adolescents) showed significantly higher mean alliance scores across all segments than participants who dropped out of treatment. Analyses a/the Factor Analyses To further examine parent and adolescent PAARS scores, a factor analysis using a Varimax rotation was conducted which yielded two main factors. In order to independently evaluate each factor, a 2 (Retention Status) x 2 (Role) x 4 (Segment) repeated measures analysis of variance was performed using the average P AARS scores for each participant at each segment on Factor 1 and Factor 2 (see Table 1 and Figures 2 and 3). 1.5 0.5 1-1 1-2 2-1 Mean Alliance for Factor Scores 2-2 • RA Comp • -RADrop jfh Mom Comp • 888 Mom Drop 3 ,----------------------------------------, 1.5 +--_.=--_--==----;;;;--I-==---~.------------t - --. 0.5 +---------------------------------------~ O+---------~--------_r--------_.--------~ 1-1 1-2 2-1 2-2 Figure 2 Mean Alliance for Factor 1 Scores 4 ... ... ~- .- .. .. .. -.... ..... .. .. - ........ .. ... .-. 3.5 .. 3 ... • - - - .. . ... - - -II- ... .. . .. -IIIiIIIIII 2.5 2 o \-\ \-2-\ Figure 3 2 Scores • RA Comp -- - RA Drop * MomComp .. • - Mom Drop .. II " RA Drop * MomComp .... " MomDrop 22 Each factor yielded a similar pattern of results to those reported earlier. For F ( l , 56) = < .001 as well as a main effect for time F ( l , 56) = 4.01,/> < .05. A significant Segment x Retention Status effect was also found F ( l , 56) = 7.91,/? < .001. Similarly, a repeated measures analysis using Factor 2 scores (positive/negative affect F ( l , F ( l = 4 . 2 7 , 23 Factor 1 (collaborative, working alliance) the analyses found a main effect for family role F(1 , = 50.44,p F(1, = 4.0l,p F(1 , = 7.9l ,p affect and desire to overcome problems in the relationship) found a main effect for role F(l, 56) = 51.95,p < .001 and a Segment x Retention Status effect F(1 , 56) = 4.27,p < .01. adolescents) or a significant decrease in alliance from segment 3 to segment 4 (for mothers). The pattern of alliances across segments found that the second segment of the second session is an important predictor of treatment completion. These analyses suggest that the interaction between outcome and segment occurs mostly in the this last segment of the second session, with completer families demonstrating a significant increase in alliance and dropouts demonstrating no change or a significant decrease in alliance for mothers. A main effect for family role was also noted, with mothers demonstrating significantly higher alliance scores than adolescents, regardless of retention status. Completer family alliance scores were also significantly higher across segments than those families who failed to complete therapy. It is also important to note that these results were found within the first two sessions of therapy. This supports previous FFT research that has found the first two therapy sessions to be "critical" in predicting retention (Robbins et al., 2003, 2006, 2008). The fact that these results were the same for DISCUSSION The results of this study demonstrate the importance of parent-adolescent relationships as they play out in Functional Family Therapy for delinquent adolescents and their single mothers. As was predicted, families who completed therapy demonstrated a positive slope of both mother-adolescent and adolescent-mother alliances while those who failed to complete therapy demonstrated no change in alliance (for the research that has found the first two therapy sessions to be "critical" in predicting retention (Robbins et aI., 2003, 2006, 2008). The fact that these results were the same for combined roles in family therapy. family patterns with therapists as predictive of retention versus dropout outcomes. Therefore, it is difficult, and even model inconsistent, to attempt to generalize any patterns seen in this study to other forms of intervention. Because these results were generated from such a specific and rigorous test of the FFT model, their importance lies in the test of the FFT model and the information they provide about changes in family alliance in relation to treatment retention. alliance scores after 20 minutes of treatment, so interpreting these results is difficult. One possibility is that families who go on to complete therapy enter into treatment at a higher, more positive level of functioning than families who eventually drop out of therapy. This would point to the importance of family factors such as family bonding prior to treatment as a strong predictor of treatment retention. If this were the case, it could be argued that 25 both mothers and adolescents (i.e., completer mothers and adolescents had higher alliance scores and demonstrated an improvement in alliance in comparison with their counterparts) also points to the importance of both the parents' and adolescents' It is important to note that this study only evaluated a single intervention: FFT. Other types of family therapy may yield a different pattern of results regarding family alliance. In fact, the Robbins et al. (2003, 2006, 2008) series of studies demonstrated that different family therapy models, in model-consistent ways, experienced different alliance Although the results provided support for the link of family alliance during FFT therapy and treatment retention, it is important to note that the difference in overall alliance between completer families and dropout families was significant as early as the first segment of the first session of treatment. The first segment represents the family 26 some families are capable of responding to treatment while others are not, regardless of the therapy itself. A counter argument is that the families all enter treatment at a similar level of functioning and bonding, and completer families simply respond to treatment quickly enough so that the differences in alliance scores can be noted after only 20 minutes of therapy. Newell, Alexander, and Turner's (1999) findings provide support for this hypothesis. Using a speech act frequency count, they examined overall levels of negativity in treatment completer families and treatment dropout families in a similar FFT population. Their results demonstrated that both completer families and dropout families entered into treatment with similar levels of negativity as measured by negative/blaming speech acts. As treatment progressed, they found that dropout families demonstrated an increase in negativity and blaming to mid-session followed by a decrease back to baseline by the end of the session. In contrast, completer families did not demonstrate this fluctuation in overall negativity across the session. These findings lend support to the hypothesis that completer families are better able to respond quickly to treatment versus dropout families. that therapy plays in improving family relations and predicting retention. Further, a third possibility combines both of these arguments and interprets these results as an interaction between family functioning and bonding prior to treatment and the therapeutic process across early FFT sessions. In other words, it is possible that completer families enter into treatment with better functioning and bonding and, as a result, will respond to the approach to treatment at a higher level than dropout families. The fact that the difference between completer families and dropout families is greatest during the last segment families decrease back to baseline by the end of the session. In contrast, completer families did not demonstrate this fluctuation in overall negativity across the session. These findings lend support to the hypothesis that completer families are better able to respond quickly to treatment versus dropout families. This argument places the importance on the treatment approach itself and the role difference if the same. family exogenous variables such as pretreatment crime rates, pretreatment family functioning and bonding, and psychopathology. Such exogenous variables could well contribute to the differences in observed results beyond the therapy process that was measured in this study (Alexander, 2004). independent, family study also did not evaluate family alliance beyond session 2 and how later changes in parent or adolescent alliances may have been related to treatment retention. Additionally, only one graduate student's ratings were used to obtain the PAARS scores for all participants which adds a level of dependency (i.e., the ratings of one participant could have been influenced by previous ratings within the rater's memory) that might not be present if two different raters were to rate each family member separately. This issue was 27 (session two-segment two) seems to support this interpretation. The next critical step would be to further evaluate this interpretation by looking at exogenous variables such as pretreatment family and crime variables, to see ifthe pattern of results would remain the Limitations While this study represents an important first step to analyzing family relationships during therapy, there were several limitations that should be addressed in future research. First, the characteristics of the population were unknown with respect to functioning In addition, only a single measure was used to assess the family alliance, and then only in the first two sessions of therapy. Although the PAARS is an independent, observational measure, important information about how the therapist and family members perceived treatment and the alliance is not included in these analyses. This Implications family's treatment. While these results are promising and useful in terms of predicting family treatment retention, future research is necessary to evaluate the multiple variables present in family therapy. Further investigations should focus on pretreatment family characteristics, therapist characteristics during therapy such as model adherence and therapeutic alliance patterns with the family, and specific therapy techniques and how all these variables interact during treatment in order to better understand the therapeutic process with delinquent adolescents and their families. 28 noted and was addressed in a couple of ways. To address rater memory, sessions were not rated sequentially in order to reduce rater memory as a potential influence within families across sessions. In addition, by using repeated measures analyses and looking at role as a within effect there is a movement towards reducing dependency statistically. However, it is understood that some level of dependency cannot be accounted for within this design but the additional steps taken reduce this concern when interpreting the results. Clinical Implications Overall, these results point to the importance of family relationships and how they evolve, or fail to evolve, during early therapy sessions. These results are an important contribution to the field in that they offer therapists a measure of how treatment is or is not progressing. By evaluating levels of family conflict, bonding, and overall alliance, therapists may be able to predict a family'S risk for prematurely dropping out of family family 1996)** him/her. him/herself. his/her his/her APPENDIX A PARENT-ADOLESCENT ALLIANCE RATING SCALE FOR THERAPEUTIC SETTINGS* Malinda J. Freitag James F. Alexander, Ph. D. University of Utah *Based on the Vanderbilt Therapy Alliance Scales Revised Version (Diamond, 1996)* * **See also Robbins, Turner, Alexander, & Perez (2003) B. To what extent did the adolescent or parent: 19. Express that he/she feels better about the "other" since the latest crisis began. 20. Indicate that he/she experiences the "other" as understanding and supporting himlher. 21. Seem to identify with the "other's" method of working, so that he/she is assumed part of the relationship himlherself. 22. Expect the "other" to change without accepting hislher own responsibility for the problems. 23. Make an effort to discuss and/or carry out suggested changes by the "other." 24. Acknowledge that he/she had problems which the "other" could help him/her deal with. 25. Indicate a desire to overcome hislher problems. i.e., his/her his/her try out off a joint 30 26. Talk freely, openly, and honestly (Le., nondefensively) with the "other" about his/her thoughts, feelings, and behavior. 27. Show a willingness to explore hislher own contribution to hislher life situation. 28. Act in a hostile, attacking, or critical manner toward the "other." 29. Act in a mistrustful or defensive manner towards the "other." 30. Indicate a willingness to discard old behavior and thought patterns and tryout new ones suggested by the "other." 31. Become so anxious in the session that it interfered with working with the "other" in a constructive manner. 32. Show evidence that he/she has missed an appointment with the "other," or hesitates to make the next appointment (i.e., late to scheduled meetings with the "other," must be recently). Appointments or meetings between family members can refer to doctor's appointments, therapy appointments, curfew, scheduled outings (i.e, "We were supposed to go to the mall but __ was late."), or scheduled times for pickup or drop-off at events (either scheduled social or business events). To what extent did the adolescent/parent and "other" together: 33. Show enthusiasm towards the "other" which made the session seem alive and energetic. 34. Work together in ajoint effort to deal with the adolescent's problems. 35. Share a common viewpoint about the definition, possible causes, and potential alleviation of the adolescent/parent's problems. 36. Relate in a realistic, honest, straightforward way, within the bounds of reasonable human interaction. and/other." 43. 37. Agree upon the goals and tasks (themes) for the session. 39. Seem to be engaged in a power struggle. 40. Express directly or indirectly the possibility of premature termination of the relationship with the "other" (i.e., no longer working as a unit). 41. Became ruminative and! or empty, without a clear trend or theme in response to the "other. " 42. Accept their different roles and responsibilities as part of their relationship. 43 . Refer back to positive experiences they have been through together. 44. Have awkward silences or pauses in their conversation. 31 APPENDIX B LOADINGS FACTOR 1 PAARS ITEMS FACTOR LOADINGS 20. Indicate that he/she experiences the "other" as understanding and supporting. 21. Seem to identify with the "other's" method of working. 23. Make an effort to discuss and/or carry out suggested changes by the "other." 26. Talk freely, openly, and honestly with the "other." Adolescent = .685 / Mother = .770 Adolescent = .770 / Mother = .684 Adolescent .442 / Mother .436 Adolescent = .838 / Mother = .544 27. Show a willingness to explore his/her own contribution to his/her life situation. Adolescent .684 / Mother .623 29. Act in a mistrustful or defensive manner towards the "other." Adolescent = .732 / Mother =.531 30. Indicate a willingness to discard old behavior and thought patterns and try out new ones suggested by the "other." 34. Work together in a joint effort to deal with the adolescent's problems. 36. Relate in a realistic, honest, straightforward way. 37. Agree upon the goals and tasks (themes) for the session. Adolescent = .444 / Mother = .465 Adolescent = .736 / Mother = .838 Adolescent .832 / Mother .797 Adolescent .863 / Mother = .569 42. Accept their different roles and Adolescent = responsibilities as part of their relationship. .636 / Mother = .668 APPENDIXB FACTOR ITEMS AND FACTOR LOADINGS ajoint = = = = = = = .838/ = = = = .531 = = = .736/ = = .832/ = = = .636/ FACTOR 2 PAARS ITEMS 24. Acknowledge that he/she had problems which the "other" could help him/her deal with. 25. Indicate a desire to overcome his/her problems. 28. Act in a hostile, attacking, or critical manner toward the "other." 39. Seem to be engaged in a power struggle. 40. Express directly or indirectly the possibility of premature termination of the relationship with the "other" (i.e., no longer working as a unit). 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