(p. 228) Interpersonal Interaction Competency
Unlike some psychologists who work primarily or exclusively with individuals, CFP specialists interact regularly in professional contexts with multiple individuals in conjoint treatment interaction. It is crucial that the CFP specialist manifest the competency to relate effectively in order to create a therapeutic alliance with individuals, couples or dyads, families, groups, and larger social systems. This chapter defines interpersonal competency, specifies the specialty knowledge base and values necessary for competency, and details specialty-level skills and abilities in interpersonal interactions. See Table 12.1 for an overview of these factors.
Table 12.1 Interpersonal Interactions: Developmental Level—Specialty Competence in Couple and Family Psychology
Competency Domain and Essential Component
Note. Adapted from the format and content of the Assessment of Competency Benchmarks Work Group (2007). This table assumes that the specialist has achieved competence in professional psychology at the three previous developmental levels, as specified in the benchmarks. The competency domains and behavioral anchors serve as the primary organizing structure for this chapter; content explaining each domain and anchor is provided in the chapter.
Definition of Interpersonal Interaction Competency
Competent interpersonal interaction in CFP entails the ability to establish and maintain an effective therapeutic relationship with individuals, couples, families, and larger social systems. Effective therapeutic relations are based on knowledge of systems theory, specific interpersonal theory, and research regarding therapeutic relationships, as well as attitudes that inform the therapeutic process. Interpersonal skills reflect the application of the attitudes and knowledge to specific abilities and techniques within the treatment interaction.
Effective interpersonal interaction may be understood as a foundational competency because it plays a role in all the functional competencies. It is especially significant in the intervention competency because it interacts with treatment model implementation to affect treatment outcomes (Sexton, 2007; see below). In addition, because CFP specialty practice often (p. 229) (p. 230) incorporates multiple individuals in the treatment room, this competency also includes the ability to model effective interpersonal relations for the clients; this constitutes a type of intervention because it can impact treatment goals that focus on improving client relationships (see Chapter 5).
Effective interpersonal treatment skills are built on a foundation of theoretical knowledge and research findings about therapeutic interaction. The ability to relate effectively is not inherent in the clinician; relationship skills develop from knowledge about the nature of interpersonal relationships within a treatment context and supervised experience in professional practice (N. J. Kaslow, Celano, & Stanton, 2005).
Foundation in Systems Theory
CFP advocates a systemic epistemology (Robbins, Mayorga, & Szapocznik, 2003; Stanton, 2009b; see Chapter 2) that includes knowledge about key systemic concepts (e.g., complexity, reciprocity, adaptation) and informs the psychological treatment of individuals in systemic context. The CFP specialist understands these systemic dynamics and acts in treatment in a manner consistent with that awareness. The CFP specialist conceptualizes interpersonal interaction that establishes a therapeutic alliance within a systemic framework that recognizes that multiple persons contribute to and are influenced by the developing alliance. In addition, the CFP specialist understands that particular systemic models of treatment define the interactional position of the specialist differently (e.g., from nondi-rective and collaborative to hierarchical and directive), so the specialist must attend to the particular treatment intervention utilized (Rait, 2000; see below). There may be different perceptions of the alliance by different individuals in treatment, and there is now evidence that gender differences in perception of alliance can exist in couple therapy that inform likely treatment outcomes (Knobloch-Fedders, Pinsof, & Mann, 2007). In addition, relationship distress between individuals in treatment and individual family-of-origin distress (poor quality of family functioning experienced as a child) predict the nature of the therapeutic alliance (Knobloch-Fedders, Pinsof, & Mann, 2004).
In that framework, the definition and manifestation of therapeutic alliance in CFP are different than in individual psychotherapy. Consistent with systems theory, the alliance is much more complex and interactive. For instance, not only might there be individual differences in alliance, but (p. 231) those alliances may vary subtly over time in treatment, and even the perception of another participant’s alliance may impact outcomes. Knobloch-Fedders and colleagues (2007) found that women’s evaluation of their partners’ treatment alliance provided an additional element toward outcomes beyond her own therapeutic alliance. In addition, it is not unusual for participation in treatment by members of the system to vary over time; the alliance may change when a new person is present or someone is missing at a session. CFP recognizes the multifaceted nature of the therapeutic alliance in systemic treatment.
Systemic models of therapeutic alliance pay attention to cultural and individual differences. This is demonstrated in a multicultural understanding of empathy in the therapeutic environment (Pedersen, Crethar, & Carlson, 2008). This model distinguishes between a convergent definition of empathy that focuses primarily on understanding an individual apart from the person’s context and a divergent definition that focuses on the person in the cultural context (Chung & Bemak, 2002); traditional individualistic psychology has emphasized the former, while systemic models of psychology rely on the latter (see Chapter 11 for diversity elements to consider in establishing the therapeutic alliance).
Finally, systems theory recognizes that when a CFP specialist is invited to join a social system to assist in system functioning, the specialist becomes part of that social system, at least for a time (Brooks, 2001; Stinchfield, 2004), with important treatment outcome implications. For example, the CFP specialist must establish and maintain appropriate boundaries: “The psychologist, while a part of the interaction in family sessions, should try to avoid siding with family members and colluding with the targeting of the identified patient…these methods help create a healthy therapeutic boundary” (Thoburn, Hoffman-Robinson, Shelly, & Hagen, 2009, p. 206). The CFP specialist must understand the nature of the role and act responsibly within the system; this requires skills that grow out of an understanding of systemic functioning.
Knowledge of systems theory is enhanced by specific awareness of relationship functioning at particular systemic levels (e.g., couple, family, and group) and in certain social circumstances (e.g., conflict). For instance, familiarity with attachment theory (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1988; George, 2009) and its relevance to CFP populations may alert the CFP specialist to client limitations in developing a therapeutic alliance and/or explain client behaviors in response to clinician-initiated (p. 232) interpersonal interactions (Obegi, 2008). While such knowledge is the foundation for particular CFP interventions, such as Emotionally Focused Couple Therapy (Johnson & Bradley, 2009), it also informs the evolution of the therapeutic alliance (Obegi, 2008).
Knowledge of communication theory in professional settings (e.g., communication accommodation theory; Watson & Gallois, 1998) ensures that the CFP specialist understands the nature of intergroup and interpersonal communication, recognizing the barriers to accurate conveyance of information or ideas (session dynamics; Mahaffey, Lewis, Walz, Bleuer, & Yep, 2008) that may impede a therapeutic alliance. Knowledge of group process theory and research on group therapy (Yalom & Leszcz, 2005) informs CFP specialist interpersonal interaction at the group or larger social systems levels. Knowledge of conflict theory (Ma, Lee, & Yu, 2008) and models of conflict style (Rahim & Magner, 1995; Thomas & Kilmann, 1978) enables the practitioner to understand interpersonal conflict, recognize conflict styles (including the style of the specialist), and enhance one’s ability to manage conflict in the treatment process. Understanding conflict is especially relevant to the practice of couple therapy (Mackey, Diemer, & O’Brien, 2000) and practice in family business or organizations (see Chapter 6). The CFP specialist demonstrates an advanced level of knowledge and the ability to apply these theories to treatment populations.
There is now research evidence that recognizes the importance of effective interpersonal relations in treatment (Norcross, 2001). Early attempts to identify evidence-based practices minimized the role of the psychologist and focused instead on procedures prescribed by treatment manuals in a manner that appeared to suggest that the person of the psychologist was relatively unimportant to treatment outcomes (Norcross, 2001). As Lebow (2006b) indicates, “Too often researchers regard the skills, personality, and experience of the therapist as side issues, features to control to ensure that different groups receive comparable interventions” (p. 132). Subsequent models of evaluation of evidence for intervention outcomes have given increased attention to clinical judgment and the interpersonal skills of the psychologist (Levant, 2004). Norcross (2001), detailing the results of an APA Division 29 (Psychotherapy) Task Force on Empirically Supported Therapy Relationships, notes that most clinicians experience treatment as an extremely interpersonal and affective interaction. He suggests that we cannot ignore that the “therapist as a person is a central agent of change,” and “multiple and converging sources of evidence indicate that the person (p. 233) of the psychotherapist is inextricably intertwined with the outcome of psychotherapy” at a level similar to the effect of a particular treatment (Norcross, 2001, p. 346).
The APA Presidential Task Force on Evidence-Based Practices (2006) considered the various perspectives on evidence-based practice and arrived at a definition that gave credence to research and clinical experience: “Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 273). Subsequently, APA Task Force members clarified that “the task force designated the use of research evidence as a component of clinical expertise” and that there is no dichotomy between clinical experience and research findings (Wampold, Goodheart, & Levant, 2007, p. 617). Among the components of clinical expertise delineated by the Task Force is interpersonal expertise. The Task Force members suggest that clinical expertise is manifested in a variety of clinical activities, including the formation of a therapeutic alliance (APA Presidential Task Force on Evidence-Based Practices, 2006).
However, debate continues regarding the relative salience of specific evidence-based models of intervention that rely on distinctive change mechanisms versus the “common factors” found across evidence-based interventions (Blow, Sprenkle, & Davis , 2007; see Chapter 5 for an overview of this issue). Evidence suggests that common factors play a significant role in the development and maintenance of the therapeutic alliance (Sprenkle, Davis, & Lebow, 2009). A comprehensive understanding of the therapist’s role recognizes the importance of how an individual therapist invokes the common factors, demonstrates interpersonal abilities, and adheres to evidence-based models to achieve positive outcomes. For example, Robbins and colleagues (Robbins et al., 2006; Robbins, Turner, Alexander, & Perez, 2003) found that in Functional Family Therapy the alliance is best achieved by a balanced relationship with the adolescent and the parents, whereas in Multidimensional Family Therapy it is best accomplished by a strong relationship with the parents. Additional research suggests that the relative importance of a balanced therapeutic relationship may vary within a particular treatment model by family ethnicity, perhaps due to different cultural expectations regarding hierarchical structure and respect for those differences in treatment (Flicker, Turner, Waldron, Brody, & Ozechowski, 2008). We suggest the recognition of a dynamic interaction between treatment models and common factors. “Just as many common factors work through models, models in turn work through therapists” (Blow et al., 2007, p. 299). The CFP specialist understands and implements common (p. 234) factors in light of intervention models in order to develop and maintain the therapeutic alliance.
Models for the measurement of the therapeutic alliance, such as the Systemic Inventory of Change (STIC®) that includes as subscales the Integrative Psychotherapy Alliance Scales (Pinsof & Chambers, 2009), including the Individual, Couple Therapeutic Alliance Scale-Revised (Knobloch-Fedders et al., 2007) and Family versions, allow progress reports to the CFP specialist about the nature of the alliance. This model evaluates alliance in two domains, Content (tasks, goals, and bonds) and Interpersonal System (self, other, group; Pinsof & Chambers, 2009). The Interpersonal System evaluation allows the clinician to distinguish different perceptions of alliance between the various levels of the system because they contribute to treatment continuation and progress (Pinsof & Chambers, 2009).
Alternatively, the System for Observing Family Therapy Alliances (SOFTA) model (Friedlander, Escudero, & Heatherington, 2006), based on systems theory, allows the clinician to collect evidence about the alliance by monitoring specific elements of the alliance, including engagement, emotional connection, safety, and shared perception of purpose, noting both patient and therapist behaviors. SOFTA research indicates that differentiation of self, a systemic concept evident in Bowen theory, has been demonstrated to predict a patient’s perception of the treatment alliance (J. E. Lambert & Friedlander, 2008).
The primary specialty attitude for the interpersonal interaction competency is a commitment to facilitating positive and constructive therapeutic relationships. Several aspects contribute to this attitude in an interactive fashion (i.e., they are not discrete attitudes or behaviors; they evidence reciprocal influence on each other), including awareness of differences in perspective between participants in CFP treatment and clinician tolerance of differences; CFP specialist expectation and comfort with the ambiguity that exists in interpersonal interactions; clinician professional attitude to value each person in professional interaction and commitment to equitable treatment; and specialist willingness to receive and respond professionally to patient feedback.
Awareness and tolerance of differences in treatment are crucial to developing a therapeutic alliance with individuals who are different than the clinician in race, ethnicity, socioeconomic status, age, gender, sexual (p. 235) orientation, spirituality, physical features, primary language, national origin, and other characteristics (see Chapter 11). Comas-Diaz (2006) adopts this broad definition of culture (i.e., extending ethnicity and race to include multiple individual difference factors and the dynamic interaction between these factors) and notes the importance of the therapeutic relationship in multicultural treatment. Cultural competence begins with a basic commitment to recognize and accept individual differences in the process of establishing a therapeutic relationship. This often requires self-reflection and exploration by the clinician of past experience, personal bias, and individual values (Constantine, Fuertes, Roysircar, Kindaichi, & Walsh, 2008; Hays, 2008). This is more complicated in CFP practice than in individual treatment because there are likely to be a variety of differences within and across the multiple individuals in treatment that may elicit therapist bias; consideration of personal development from a cultural perspective may assist the CFP specialist in developing positive attitudes toward difference (Bobes & Bobes, 2005; McGoldrick, Giordano, & Garcia-Preto, 2005).
Tolerance of ambiguity is an important characteristic for CFP practitioners. “Tolerance for ambiguity implies that one is able to deal with uncertainty and/or multideterminacy.…Ambiguity-tolerant people are comfortable with the shades of gray in life” (Beitel, Ferrer, & Cecero, 2004, p. 569). Tolerance of ambiguity refers to the fact that interpersonal interaction often results in vague, imprecise, or uncertain meanings. In fact, when interacting with multiple individuals, there are often multiple interpretations of what has occurred. CFP specialists need to be able to understand and hold several perspectives at once in order to create an effective alliance with couples, families, or larger groups. This is consistent with a constructiv-ist perspective that suggests that meaning is socially constructed (Gergen, 1985) through dialogue. Gelatt (1989) presents a “decision and counseling framework that helps clients deal with change and ambiguity, accept uncertainty and inconsistency” (p. 252) in the face of increasing ambiguity today. This model is consistent with a systemic epistemology. Termed positive uncertainty (Gelatt, 1989, p. 252) because Gelatt suggests that it is possible to be comfortable with the ambiguity we face regularly in interpersonal interactions, the model provides three guidelines for organizing information to determine a course of action: (a) information: information is more readily available today than before, but some level of uncertainty is beneficial because information is often ambiguous and changing; (b) process: goals may be discovered in the process of considering information to achieve decisions instead of setting goals and deciding how to get there; and (c) choice: therapists must reconsider excessive reliance on rational (p. 236) thought processes in decision making to embrace intuitive thinking and encourage the flexibility to both create change and respond to it (Gelatt, 1989, pp. 254–255). The CFP practitioner must be comfortable enough with ambiguity to facilitate this process. Pedersen et al. (2008) indicate that becoming comfortable with ambiguity is one element in developing multicultural empathy.
A professional commitment to equitable treatment that values each person in the treatment interaction is essential for CFP practice. For instance, a frequent concern in couple therapy involves gender equity; does the CFP specialist make stereotyped attributions based on gender, or does the CFP practitioner evaluate the cause for relationship events differentially based on gender? (Stabb, Cox, & Harber, 1997). Social psychology tells us that fairness is a common human value and that procedural fairness (the manner in which people are treated) results in a fair process effect (perceived fairness positively impacts future reactions) that positively influences future relations (van den Bos & Miedema, 2000). Procedural fairness concerns may arise when one person dominates the treatment session, when it appears that one person is being blamed for couple issues, or when individual differences between a patient and the CFP practitioner seem to result in clinician behavior that devalues one person. The CFP specialist may anticipate potential concerns regarding inequitable treatment by raising the issue at the onset of treatment, especially if it appears that some such perception may be present and may inhibit development of a therapeutic alliance. The practitioner may well establish practice norms and communicate them when treating multiple individuals (e.g., couples, families, groups). For example, when initiating couple therapy, the specialist may inform the partners that he or she makes every effort to be fair to both partners, but that a particular session may appear to focus more on one person or the other. Or the practitioner may make a comment that one partner could understand as unfair and invite each partner to express any concerns about inequitable treatment in session. At that point, specialist openness to patient feedback is important.
Practitioner willingness to receive and respond professionally to patient feedback can help establish the therapeutic alliance and avoid disruption of it. If a patient raises a concern about the professional behavior of the clinician, it is important that the specialist not react defensively. Defensiveness in CFP practice has been conceptualized as reciprocal and circular, so that therapist defensiveness engenders a defensive response from patients in a manner that undermines the therapeutic relationship; in addition, therapist defensiveness has been found to result in poorer outcomes for couple (p. 237) therapy (Waldron et al., 1997). Consequently, the critical attitude involves openness, equality, and responsiveness instead of dogmatism, superiority, and control over the relationship (Waldron et al., 1997). A nondefensive response that reflects accurate empathy and understanding for the concern raised and clarifies the specialist’s intent in the questioned situation may resolve the difficulty or allow continued dialogue about the concern. Willingness to provide a referral to another clinician may be necessary (e.g., if the specialist is male, and a female patient has questioned gender bias, a referral may be made to a female specialist); this offer can demonstrate genuine concern to address the issue in a manner that may allow further discussion and possible resolution of the issue with the original clinician. Some CFP specialists or treatment clinics routinely use client satisfaction surveys to ensure frequent feedback from patients (Fischer & Valley, 2000; Pinsof & Chambers, 2009).
Interpersonal Interaction Skills
A variety of clinician-offered relationship qualities have been identified in CFP literature relative to creating and maintaining effective therapeutic relationships with clients. This section will review these interpersonal skills in light of the comprehensive and complex model noted above that includes speciaist manifestation of the common factors, interpersonal relationship abilities, and adherence to evidence-based models. It may not be assumed that particular manifestations of common factors will uniformly impact treatment in a positive fashion because the interpersonal skills should align with the specific treatment model used (Sexton, 2007). In addition, certain skills may be more important for some treatment than for others (e.g., managing conflict and providing safety may be more important for high-conflict couples or families experiencing physical abuse). In this section, we will describe interpersonal interaction skills at the onset of treatment, during treatment, and at termination of treatment.
Interpersonal Interaction Skills at Onset of Treatment
The literature on the role of interpersonal interaction between the clinician and the clients clearly identifies the importance of establishing a therapeutic alliance quickly in treatment. For example, in a study about couple therapy, Knobloch-Fedders et al. (2007) found that “the therapeutic alliance formed quickly, and remained relatively stable from the first session to the eighth session of treatment. It appears that couples’ immediate perceptions of their therapists (formed during the first session) remain well (p. 238) established, at least as the therapy moves into the mid-treatment phase” (p. 255). They suggest that developing the therapeutic alliance is among the most critical tasks of the initial couple session.
Rapid establishment of a positive therapeutic alliance requires specialist characteristics and skills that will engage the clients, such as interpersonal warmth, empathy and caring, conveying expertise, appreciation of client expertise, and ability to establish an appropriate balance in alignment with different members engaged in couple, family, or larger group treatment.
Interpersonal Warmth, Empathy, and Caring
Therapist-offered factors frequently mentioned as important in establishing a therapeutic alliance include various aspects of friendliness, interpersonal warmth, and genuineness, often demonstrated as empathy and caring in treatment. This is noted by Blow and colleagues (2007), “Regarding therapeutic style, therapist positivity/ friendliness is consistently associated with good outcome, and criticism / hostility has the opposite impact” (p. 304). The CFP clinician must develop the skills to communicate interpersonal acceptance, friendliness, and warmth quickly and clearly to the new clients. When clients are troubled or facing difficult challenges, most want to know that the person helping them both accurately understands their situation and cares about helping them. Obegi (2008), drawing on attachment theory, indicates that “clients seek therapists because doing so is expected to alleviate distress” (p. 433). Friedlander et al. (2006) suggest the importance of this dimension through the inclusion of the dimension “emotional connection” between therapist and client(s) in their SOFTA model of therapeutic alliance, indicating that it is “based on affiliation, trust, caring, and concern; that the therapist genuinely cares and ’is there’ for the client” (p. 88). They note that “clients value therapists who are warm, active, down-to-earth, informal, trustworthy, optimistic, secure, humorous, caring and understanding” (Friedlander et al., 2006, p. 90) and indicate that clients who do not find these characteristics in the therapist may not contribute important information early in treatment, inhibiting assessment and treatment.
The desired outcome at the end of the first session is the client perception of a positive therapeutic alliance with the CFP specialist because it contributes significantly to change and treatment outcomes (Blow et al., 2007; Knobloch-Fedders et al., 2004). The early alliance has a strong impact on the continuing alliance (Knobloch-Fedders et al., 2007).
One demonstration of specialist empathy and caring is the skill of adapting one’s style of interaction to the expectations and desires of the clients (p. 239) (Blow et al., 2007). It is possible to vary one’s style of interaction according to the needs of the moment in order to maintain the conditions that facilitate change. Another is skill in demonstrating respect for clients’ cultures and aligning interventions with cultural values and beliefs; Muir, Schwartz, and Szapocznik (2004) term these culturally syntonic interventions because they are in tune with the clients.
Finally, it is important for the clinician to know how the clients perceive the therapeutic interaction. This requires the interpersonal skill of questioning the perception of the relationship in a friendly and caring manner. For instance, it is our practice to ask the clients at the end of the first session about their perception of the therapeutic alliance (e.g., “How do you feel about working with me on these issues?” or “Do you feel like you can talk openly with me about your problems?”). This allows the CFP specialist to process initial perceptions of the therapeutic alliance before the end of the first session, discussing any difficulties and/or correcting any misperceptions. Alternatively, a client feedback survey may elicit similar information after the session (see case examples in Pinsof & Chambers, 2009).
The ability to convey professional expertise is a skill that requires careful attention to avoid the errors of arrogance and condescension, on the one hand, or self-effacing humility that undermines the clients’ confidence in the specialist, on the other hand. When individuals seek treatment in the midst of challenging circumstances, it is crucial that they perceive that the clinician is capable of working with them to address their concerns.
This does not require a directive or “expert” style; it may be accomplished by accurate understanding of the presenting issues and clear communication that the specialist has a procedure to address those issues. It often involves the instillation of the perception that the presenting issue(s) did not shock, offend, or rise above the education, training, and experience of the clinician (Blow et al., 2007). The desire is to create an awareness of specialist experience with similar issues (“I’ve been around this block before”) and a perception of specialist competence to work with the clients on them in therapy (“I have some ideas about how we can work on this”). It should be possible for the clinician to summarize the presenting issues and to discuss or negotiate initial therapeutic goals by the end of the first session. This provides a concrete sense of direction to the clients and conveys the capability of the specialist to help facilitate change, enhancing “engagement in the therapeutic process” (Friedlander et al., 2006, p. 72).
(p. 240) There is some confound in the research about the role of the level of experience in achieving treatment outcomes (perhaps because expertise has not been determined by clear competency measures, such as ABPP examination, in the research), but it has been suggested that it may be most significant when treating challenging clients and complex problems (Blow et al., 2007). In our practice, we have found that it is beneficial to ask the clients at the end of the first session (after the synopsis of presenting issues and suggested treatment plan, noted above) if they believe this is a place where they can find the assistance they desired when they called for an appointment. As Sprenkle and Blow (2007) note, “Clients need to view the ’tasks’ of therapy as credible, and if what the therapist is doing does not fit with their expectations, or the therapist cannot sell them on the merits of the approach, it matters little what the therapist believes” (p. 111). In a manner similar to feedback on the perception of personal characteristics, this allows the clients to express their perception about the potential effectiveness of the specialist and the proposed plan of action, and it provides an opportunity for the specialist to respond by modifying and/or clarifying the plan.
Appreciation of Client Expertise
Anderson (2009), practicing from a constructivist approach, advances the idea that both the clinician and the clients contribute expertise to the therapeutic engagement. He suggests that the “client is an expert on themselves and their world; the family psychologist is an expert on a process and space for collaborative relationships and dialogical conversations” (Anderson, 2009, p. 308). This is especially important in CFP practice because of the complexity of multiple perspectives and compound information. The specialist must develop the skill of conveying respect and appreciation for the expertise of the clients because “it calls our attention to the client’s wealth of know-how on his or her life and cautions us not to value, privilege, and worship the family psychologist as a better knower than the client” (Anderson, 2009, p. 308). So, for instance, the clinician may invite the clients to correct any specialist misperceptions about the clients and the relative fit of session interaction to their circumstances to establish a truly collaborative process.
Establish Balanced Alignment
A final critical skill in early treatment is the ability to establish a balanced therapeutic alignment with the various individuals, dyads, or subsystems in treatment. The exact nature of the alignment should reflect the (p. 241) specifications of the treatment model (Sexton, 2007) and the particular needs of the social system in treatment (Blow et al., 2007) in order to achieve the evidence-based outcome, so the specialist must monitor treatment adherence. In addition, it requires a careful assessment of system dynamics by the CFP specialist and the ability to accommodate the needs of the system instead of a rigid adherence to one’s own preferences or tendencies. For example, certain ethnic or cultural expectations may need to be accommodated (Flicker et al., 2008). The clinician needs the skill to listen carefully and observe body language or other signs of feedback from the clients about the alignment (e.g., disengagement, arguing with the specialist), and the skill to adjust the balance of the alignment as needed over the course of treatment, using alliance techniques. We have found that it is sometimes helpful to bring perceptions of change in the therapeutic alliance into the session in order to discuss specialist perception of the change and to allow the clients to clarify their perceptions so that adjustments can be considered (see below).
Interpersonal Interaction Skills During Treatment
The CFP specialist needs to evidence advanced interpersonal interaction skills during treatment. Skills needed include the ability to continue and enhance the therapeutic alliance, advanced proficiency in communication, skills for handling complexity, and conflict management abilities.
Skills to Continue Development of Therapeutic Alliance
Thoburn et al. (2009) indicate that the “development of the therapeutic alliance, both with individual family members and with the family as a whole, is an important initial process that begins during assessment and continues throughout treatment” (p. 206). This means that the practitioner must monitor interpersonal interaction in vivo in order to notice any degradation of the therapeutic alliance and/or any opportunities to enhance it and respond appropriately. Monitoring interpersonal relations is a skill developed in training that involves learning how to interact with and simultaneously analyze the nature and patterns of that interaction. In other words, the specialist cannot simply relate to the clients; the specialist must mentally observe the interaction from another level in order to gauge the effectiveness of the interpersonal dynamics and record any indicators from the clients of changing perceptions of the alliance. “Thus, when a family member indicates that the therapy is not useful, implies that the process is blocked, or shows indifference to what is being discussed or proposed, the therapist must recognize the threat to the alliance and redirect (p. 242) his or her efforts” (Friedlander et al., 2006, p. 73). This is more complex in CFP practice because multiple individuals may be present in the treatment room. Live supervision (see Chapter 8), review of session video recordings, and/or co-therapy may enhance the clinician’s skill in this area (Celano, Smith, & Kaslow, 2010).
Responsiveness, which is the skill of appropriate reaction to clients’ concerns about the treatment alliance, has been shown to positively impact treatment outcomes. Knobloch-Fedders et al. (2007) found “that subtle shifts in the alliance through mid-treatment are associated with treatment responsiveness, at least for women. Women’s alliance scores at mid-treatment made a unique contribution to the prediction of improvement in marital distress, over and above their early treatment alliance scores” (p. 255). They indicate that this implies that the clinician must demonstrate attention to the alliance and ensure that positive engagement continues throughout treatment.
Competent communication in CFP treatment involves the ability to listen, demonstrate understanding, and send clear and direct messages to multiple individuals concurrently, recognizing that communication can be misinterpreted or perceived differently by various individuals in the room. These skills are most often honed in supervised experience of CFP practice with couples, families, and groups. Verbal reinforcement, a behavioral technique, and motivational language may be especially helpful when dealing with difficult problems like substance abuse (J. E. Smith & Meyers, 2004). Measures to evaluate the therapeutic alliance, such as the SOFTA self-report version (Friedlander et al., 2006), include items such as “The therapist understands me” and “The therapy sessions help me open up” or “It is hard for me to discuss with the therapist what we should work on in therapy” (p. 298) to evaluate communication proficiency. The STIC therapeutic alliance scales (Pinsof & Chambers, 2009) includes similar items (e.g., “The therapist does not understand me” [p. 443]) to examine how the clients interpret the alliance. These items relate to specialist ability to convey understanding through communication skills.
Skills to Manage Complexity
Because a systemic epistemology recognizes the salience of multiple factors in treatment and because there are often two or more clients in conjoint, family, or group treatment, the CFP specialist must be able to manage complexity. This involves monitoring all system factors, screening information (p. 243) for salience to the treatment goals, and holding multiple client perspectives concurrently.
The basic skill needed to monitor system factors involves clinician inter-nalization of a multifactor paradigm (Stanton, 2009b; see Chapter 2) that allows the specialist to consider all possible individual, interpersonal, and environmental aspects that may be important in a particular case and readily categorize that information for organization and retention. The next skill involves screening the wealth of possibly important information to determine which factors are most salient to the treatment goals. This requires prioritization methods based on the knowledge and experience of the specialist and understanding of the clients’ prioritization. In our experience with complex cases, the organization and screening of factors is itself helpful to clients in determining more exactly the issues they want to address in treatment. This skill facilitates joint determination of treatment goals, an important aspect of the therapeutic alliance (Pinsof & Chambers, 2009).
The ability to hold multiple client perspectives simultaneously requires the specialist to understand the tenets of social constructivism and apply them to an ongoing treatment. It involves the ability to demonstrate accurate empathy and understanding to each person in treatment, even when that person’s perspective differs significantly from that of others in treatment. CFP practice includes the ability to move treatment toward addressing all perspectives and all goals. In some cases, it may be possible to bring disparate perspectives into greater alignment by helping each person to understand the role of perception and negotiating shared perceptions. It is always important to consider the treatment goals of every involved client. For instance, the STIC model includes both a “Self” dimension that measures individual alliance to the clinician and an “Other” dimension that measures each person’s perception of the alliance between the clinician and other key people in the client’s life (Pinsof & Chambers, 2009). For example, the Couple form includes the item “The therapist understands my partner’s goals for this therapy” (p. 442). Multicultural competency skills (Comas-Diaz, 2006) are relevant here as they parallel CFP practice; the CFP specialist must often interact across cultures in multiple ways even in a particular couple or family (e.g., interracial marriage, differences between first- and second-generation immigrants in a family, different religious identities).
Conflict Management Skills
A final aspect of interpersonal interaction that impacts the therapeutic alliance is the ability of the specialist to handle interpersonal conflict in (p. 244) a manner that creates the perception of safety by the clients. Flicker et al. (2008) note that an important part of the therapeutic alliance requires clinicians to “simultaneously establish and manage relationships with multiple family members who are often in conflict with each other” (p. 167). Celano et al. (2010) suggest that techniques such as “diffusing hostile exchanges, minimizing blaming attributions among family members, and promoting a relational or systemic view of the problem behavior” (p. 37) are important to the alliance. Friedlander et al. (2006) connect client feelings of safety to trust in the therapist and the specific actions the therapist takes to ensure safety, noting especially that “therapeutic handling of intrafamilial hostility is undoubtedly the most important factor in creating safety” (p. 111). This means that the specialist must be able to tolerate a necessary level of interclient conflict (i.e., the specialist may not be conflict avoidant, shifting focus away from existing tension) and have the skill to manage levels of conflict in the session in a manner that allows conflict to surface without escalating to inappropriate verbal or physical behavior (“contain and conrol the conflict”; Friedlander et al., 2006, p. 119). The clinician must monitor nonverbal and verbal behaviors for signs that signal that one or more of the clients feels unsafe and then intervene in a timely fashion to establish safety. The STIC includes an item on the Family scale that assesses the perception of safety, “Some of the other members of my family and I do not feel safe with each other in this therapy” (Pinsof & Chambers, 2009, p. 443), while the SOFTA measure of therapeutic alliance includes a 12-item scale on safety in the treatment system (Friedlander et al., 2006, p. 273).
Blow et al. (2007) indicate that
another consistent finding is the importance of therapists utilizing a sufficiently high level of activity /directiveness to prevent couples and families from simply replaying their dysfunctional patterns; and giving the session enough structure to encourage family members to face their behavioral, emotional, and cognitive issues. (p. 305)
Part of structure includes ensuring the equitable treatment of all parties in conflict situations, including fair allocation of time in the session, monitoring and managing perceived power differentials, disallowing interruptions, and teaching accurate empathy to replace hostile attacks. An adequate therapeutic alliance must include the establishment of a safe environment for exploration of interpersonal conflict.
(p. 245) Interpersonal Interaction Skills at Termination of Treatment
After some level of success in achieving the treatment goals, it is appropriate for the CFP specialist to consider how to facilitate treatment termination. The therapeutic alliance remains central to that process. If, as some studies suggest, the creation of a therapeutic alliance means that the clinician has become a quasi family member (Friedlander et al., 2006), termination requires appropriate attention to client feelings about ending an active phase of that relationship. It is likely that the clients will experience some mix of loss, sadness, and joy at the prospect. If the treatment alliance is conceptualized as a form of attachment and part of the process involves internalizing a positive therapeutic alliance (Obegi, 2008), it may be possible to consider termination as achievement of the final treatment goal. In our experience, it is not unusual for long-term clients to mention “hearing your voice” when encountering situations discussed in treatment, so the effects of the therapeutic relationship may continue after termination as the clients continue to pursue the issues addressed in treatment.
Termination requires an extension of the same skills used to establish and maintain the therapeutic alliance. Empathy, caring, and genuineness must be evident in order to process the clients’ affect and determine a satisfactory plan for treatment termination. The CFP specialist will establish clear boundaries regarding possible reengagement in treatment and clarify policies about providing other forms of treatment than the one being concluded (e.g., individual psychotherapy after family treatment).
The ability to create and maintain a positive therapeutic alliance in a variety of treatment modalities is an essential aspect of CFP practice. This requires fundamental knowledge about interpersonal interaction, as well as attitudes, skills, and abilities to enact the alliance.