Processof changeresearchinsft chapter

The Handbook of Systemic Family Therapy: Volume 1, First Edition. Edited by Karen S. Wampler,
Richard B Miller, and Ryan B. Seedall.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
8
Life is a journey, not a destination.
(Ralph Waldo Emerson)
Scaling a mountain is a difficult but worthwhile activity, and one thing every moun-
tain guide knows is that having a map and following an outlined pathway to the sum-
mit is often critical—even lifesaving. In much the same way, having a map and knowing
the pathways to specific outcomes in systemic family therapy (SFT) is imperative.
Much of the research in SFT, however, has focused on whether SFT is effective (see
Carr, 2020, vol. 1, for a definitive review of the outcome research). Without a doubt,
this is an important question—very few people want to scale a mountain without a
view! But, while knowing that SFT works is vital, knowing how it works is equally so.
These two questions—what works and how it works—may be considered two sides of
an SFT effectiveness coin; we cannot have one without the other. Research into how
therapy works is called process research (Orlinsky, Grawe, & Parks, 1994) where spe-
cific questions about the mechanisms and contexts of change and their subsequent
answers can provide guideposts for desired therapeutic outcomes. Process research has
led to many important advances and clarity in individual psychotherapy (Tompkins &
Swift, 2015); however, SFT is, simply put, a different mountain to climb.
We begin this chapter by describing the challenge and opportunity of clearly defin-
ing systemic process research. We then take a close look at the processes of change
that have been explored among various schools of therapy and empirically supported
treatments (ESTs). Afterward, we make a case for identifying common and specific
systemic process factors that can be drawn upon by all therapists seeking to do sys-
temic work regardless of their professional or model orientation. This synthesis and
integration provides an invaluable resource for a new generation of process‐informed
systemic therapists. Subsequently, we describe how the current process findings can
be integrated into training programs and practice.
The Process of Change in Systemic
Family Therapy
Nathan R. Hardy, Allen K. Sabey, and
Shayne R.
Anderson

172 Nathan R. Hardy, Allen K. Sabey, and Shayne R.
Anderson
Defining SFT Process Research
In 1989, William Pinsof provided the first definition of SFT process research as
follows:
Family therapy process research studies the interaction between therapist and family
systems. Its goal is to identify change processes in the interaction between these sys-
tems. Its data include all of the behaviors and experiences of these systems and their
subsystems, within and outside of the treatment sessions, that pertain to changes in the
interaction between family members and in their individual and collective levels of
functioning. (p. 54)
This definition acknowledges various systemic factors that SFT process researchers
should be concerned about. For example, a systemic family therapist must balance
alliances with different family members simultaneously and alter interactions between
them in sessions. This level of process is complex and quite unique to SFT and deserves
particular attention in our research. The above definition also provides a broad view
of what process research entails. Whereas the distinction between process and out-
come provides a helpful dichotomy, it can also be somewhat arbitrary as the two are
mutually influencing and encompass a circular process in which change processes can
represent desired outcomes and desired outcomes may be processes that predict
future change (Pinsof, 1989). Hence process and outcome represent evolving and
circular constructs that inform one another—like a spinning coin. As Pinsof puts it,
“all family therapy research [is] process research.”
Some opt for a narrower definition that emphasizes therapy‐specific processes
including therapist intervention and client responses that occur within treatment ses-
sions, as opposed to investigations of inputs (e.g., pretreatment conditions) and out-
puts (e.g., clinical progress; Oka & Whiting, 2013). Although this definition simplifies
matters, we cannot adequately understand and derive implications from research that
does not place these therapeutic processes in their proper context (i.e., accounting for
the input and output variables). Therefore, in this chapter, while we generally evaluate
the within‐session change processes as our central focus, we also place these within a
larger backdrop of other important contributing factors that define the processes of
change in therapy—which we describe next.
Disentangling process variables
When we investigate outcomes, we are generally looking at what has been termed “big
O” outcomes, or the more distal, end of treatment, outcomes (Kiesler, 2004). These
are usually predefined outcomes representing the main targets (presenting problem/
symptom/disorder) of therapy. This is an important distinction because there are many
proximal, or “little o,” outcomes of therapeutic processes that are related to these
larger targets and should be closely inspected in connection with in‐session change
processes (Kiesler, 2004). For example, some ESTs seek to reduce adolescent sub-
stance abuse (the big O), but what often precedes this reduction are changes in family
functioning (the little o), something systemic therapies specifically target through join-
ing, reframing, and enactments. Thus, “little o” outcomes often represent mediating
change processes. They are important to recognize when evaluating process research,

Processes of Change in SFT 173
because there are many indirect pathways, or mechanisms of change, in which inter-
ventions reach desired outcomes in therapy and are part of the larger map of how
therapy works (they are like the mini‐summits on the way to the major summit of a
mountainous trek). Therapeutic processes (e.g., within‐session events) are also often
considered mechanisms of change, or mediators of outcomes.
On the other hand, moderating variables generally represent relatively static
variables that provide conditions for therapeutic change, such as characteristics of
the client, therapist, and external systems. These not only include contextual
membership factors such as client race, therapist gender, or strength of a neigh-
borhood, but can also include therapy‐centered factors such as client’s pretreat-
ment distress level, therapist treatment adherence (or fidelity), or the number of
family members directly involved in therapy (Heatherington, Friedlander, &
Greenberg, 2005). Before planning for a mountainous trek, it is important to
check the weather first—the conditions have a lot to do with how hazardous or
stable the journey will be.
In sum, there is an important backdrop to the nitty‐gritty work of unpacking how
therapeutic processes make treatment work that cannot be ignored. For simplicity, we
opt for a more therapy‐friendly language that provides two important definitional
points: mechanisms of change (mediators) and contexts of change (moderators) in which
both may encompass in‐session and out‐of‐session characteristics and processes.
Hence, our review that follows will describe and evaluate the mechanisms and con-
texts for systemically oriented therapeutic change that exist in the literature.
Defining systemic processes of change
Process research from general psychotherapy usually considers the characteristics of an
individual client, therapist behaviors directed toward the individual client, and the
individual client response. We have learned much from, and are grateful for, the clini-
cal wisdom and research generated from within individual psychotherapy. SFT, how-
ever, must cast a wider net. Placing a problem between two, three, or more clients
brings the totality of each individual and the relationship between them together into
one “client system.” What’s more, a therapist’s behaviors must be multidirected, and
mixed responses from family members may be apparent from total engagement in one
to total disengagement in another. Individual characteristics, of course, matter in all
of this, but the processes of systemic therapy are more complex. Even when working
with individual clients, there is always a direct and indirect (i.e., there are usually peo-
ple involved in or aware of the problems of the client) client system that SFTs ideally
attend to (Pinsof, 1995). This chapter articulates those systemic processes that exist
in the literature.
Process Research on the General Schools of Family Therapy
Graduates from SFT master’s training programs are usually taught and learn to prac-
tice from the core set of schools of family therapy rather than from manualized treat-
ments typically tested in randomized controlled trials (RCTs). Although this type of
training remains controversial (e.g., Dattilio, Piercy, & Davis, 2014), we have chosen

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to comment on the process research from these general schools of therapy so as to
provide research guidance on their use by students and practitioners.
Modern and systemic models
In spite of the modern (“positivist”) epistemological climate of yesteryear, the earliest
traditions of family therapy did not generally pursue research support, and hence
there is little (if any) process research to date. For example, Bowen family systems
therapy and psychoanalytic family therapy have no outcome or process research
(except for some rare case studies) nor have they been well integrated into couple‐ or
family‐focused ESTs (insight‐oriented couple’s therapy is one exception to this;
Snyder & Wills, 1989). Two recent studies (van der Meiden, Noordegraaf, & van
Ewijk, 2018a, 2018b), however, qualitatively explored the process of change in con-
textual family therapy—sometimes categorized among psychoanalytic or intergenera-
tional traditions. Three primary therapist behaviors were used by contemporaries
including eliciting care patterns, exploring the client’s situation, and directing the
process. Other common methods included empathy, acknowledgment, dialogue, and
addressing the past. An analysis of Ivan Boszormenyi‐Nagy’s therapy identified multi-
directed partiality (e.g., balancing alliances), uncovering the balance of give and
receive, and executing a transgenerational maneuver as the most common methods.
The school of cognitive‐behavioral family therapy has greater research support,
though this usually comes in the form of research on ESTs (parent training programs,
functional family therapy, and various behaviorally oriented couple therapies), which
we describe later.1
Strategic, experiential, and structural models have limited process research, but
these models have formed the basis of several of the current adolescent‐focused fam-
ily‐based ESTs where process research has been explored more extensively. No pro-
cess studies have ever been conducted on the three traditional strategic models
(MRI, Haley–Madanes, and Milan) nor on Satir’s experiential (human validation
process) model. Whitaker’s symbolic experiential family therapy was explored only
through one qualitative analysis, which identified several processes of change (Mitten
& Connell, 2004) including shifting focus from the identified patient to the family
system, “joining” the family system, shifting from content to the family’s use of sym-
bolism, using anxiety to trigger growth (especially when therapy is stuck), amplifying
the family’s symbolic experience, and exiting the family system. A qualitative analysis
of structural family therapy (M. Nichols & Tafuri, 2013) identified 25 different ways
therapists moved families from a linear to a systemic understanding of the problem
following a four‐step assessment process: “(1) broadening the definition of the pre-
senting complaint to include its context, (2) identifying problem‐maintaining inter-
actions, (3) a structurally focused exploration of the past, and (4) developing a shared
vision of pathways to change” (p. 207). Minuchin’s “stroke and kick” form of ther-
apy (Minuchin, 1974) received empirical support in that actively eliciting, empathiz-
ing with, and accepting family member’s points of view were important prerequisites
to challenging and restructuring their interactions and led to more successful in‐ses-
sion changes (Hammonds & Nichols, 2008). Further, the elements of successful
versus unsuccessful enactments—an important part of Minuchin’s restructuring pro-
cess—was explored (M. P. Nichols & Fellenberg, 2000), the details of which are
described later.

Postmodern models
In spite of “post‐positivist” sentiments, postmodern models, such as solution‐focused
and narrative therapies, emerged when process research had become more common-
place. Further, although these models came out of SFT, they are widely recognized
for their suitability in individual psychotherapy and have become widely popular.
Hence, these schools of therapy have more process research though much of it often
represents individual therapy processes. For instance, solution‐focused therapy has an
impressive pool of research; a meta‐analysis conducted on 33 process research studies
(Franklin, Zhang, Froerer, & Johnson, 2017) found that the co‐construction of
meaning and strength‐oriented techniques were the most empirically supported
mechanisms of change.
Nine of the 33 studies, however, did deal specifically with couple or family work.
Two case studies demonstrated how therapists push for and maintain a focus on
exceptions and solutions in couple therapy (Franklin, 1996; Gale & Newfield, 1992).
Creating a focus on future‐oriented goals and a context for positives and strengths in
the first session helped families experience more compliance with treatment, clarity of
treatment goals, and improvement in the presenting problem (Adams, Piercy, &
Jurich, 1991), though this was generally not more impactful than a problem‐focused
approach—except on ratings of sessions being more smooth, impactful, positive,
deep, and leading to more optimism about the problem (Jordan & Quinn, 1994).
However, one study found mothers of a child with intellectual disabilities to find the
miracle question irrelevant though SFBT techniques did help facilitate a therapeutic
relationship and increase self‐efficacy (Lloyd & Dallos, 2008); another study found
executive and joining skills to be more predictive of outcome than solution‐focused
interviewing with families (Shields, Sprenkle, & Constantine, 1991); and finally, one
study found the technique of asking about pretreatment changes was not related to
change in outcome and pretreatment changes did not appear to persist (L. N. Johnson,
Nelson, & Allgood, 1998). Needless to say, there are likely some aspects of solution‐
focused therapy that are more effective than others and some of this may depend on
the context. Mainly, this research suggests that an overall focus on positives, strengths,
future‐oriented goals, and solutions can help create a context for hope and optimism
as therapists address problems, provide support, and seek to create change.
We located a total of seven SFT process studies of narrative therapy (we found 12
individual‐focused process studies). A qualitative analysis of eight families’ experience
of narrative therapy highlighted commonly emphasized therapeutic processes includ-
ing externalizing conversations, unique occurrences, personal agency, and reflecting
teams (O’connor, Meakes, Pickering, & Schuman, 1997). A textual analysis of
Michael White doing couple therapy found an overarching theme of “decentering”
the couple’s unfolding narrative and its embeddedness in the larger cultural discourse
by using matching/self‐disclosure, reciprocal editing, turn management to de‐objec-
tify, expansion questions, and reversals (Kogan & Gale, 1997). Another study of eight
families comparing successful and unsuccessful sessions explored a model of practice
and outlined a successful change process: family members express their individual
views, family members experience an affective change as new stories emerge, and hope
and the possibility of change are acknowledged. Noteworthy in this study is that
acknowledging family structure and generational patterns were common to trans-
formative experiences (Coulehan, Friedlander, & Heatherington, 1998).

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An intervention was used to help families dialogue about emotional disorders and
found that informal codes/norms about these disorders keep them private, but when
therapists provide a perspective about the importance of dialoguing, it led to new
shared meanings (Focht & Beardslee, 1996). One interesting study on how families
talk about domestic violence found that when families voice hesitation, and therapists
respond by voicing reassurance, families are more likely to tell their stories about it
(Rober, von Eesbeek, & Elliot, 2006). Finally, Ramey and colleagues explored the
new use of scaffolding conversations with children and found that therapists are able
to move children through the process (name, consequences, evaluate, intentions, and
plans) in one session (Ramey, Tarulli, Frijters, & Fisher, 2009; Ramey, Young, &
Tarulli, 2010). Similarly to solution‐focused therapy, these studies suggest that narra-
tive therapy also creates an optimistic context though their methods somewhat differ
with a clear focus on re‐storying clients lives by assisting the family in clarifying and
expanding new narratives that bolster personal agency and new shared meanings.
Summary of the traditional schools of SFT
In spite of polarized traditions (e.g., modern versus postmodern), the process studies
conducted on the traditional schools of SFT illuminate several core methods of prac-
tice that find some common ground in spite of their differences. Building balanced
alliances that emphasize warmth and acceptance of family members while shifting
families focus toward systemic patterns, positives moments, or new stories are com-
mon trends in engaging and motivating family members in the process of change.
Creating change also often involved an emphasis on new dialogue, interactional
change, and personal responsibility/agency – all prompted by the SFT in various dif-
ferent ways.
There may be important differences that leverage change in unique ways—the suc-
cess of which may depend upon context specific variables (e.g., the issue of concern,
the motivation of family members, the worldview of the therapist). At this point,
however, there is insufficient research on which change processes matter more in
which contexts simply by evaluating the traditional schools of SFT. Incidentally, this
research may, in some cases, affirm the prospect of integrating methods (e.g., narra-
tive therapy’s use of intergenerational and structural dynamics; Coulehan et al.,
1998). While some of the schools of SFT have received more process attention than
others, many of them have formed the basis of ESTs that have been more central in
SFT research.
Process Research in Empirically Supported Treatments in SFT
Some argue that the general schools of family therapy are too broad to provide suffi-
cient guidance on SFT practice and research exploring mechanisms and contexts for
change (Sexton & Datchi, 2014). Regardless, the emergence of highly specialized
integrative treatments for specific issues and populations—which incorporate ele-
ments from various schools of therapy—have become the center of research in SFT
(Sexton & Datchi, 2014). What follows is a review of the process research that has
emerged in both family‐focused and couple‐focused contexts. As each model provides

a unique context in which SFT is practiced, we highlight the mechanisms of change
by model followed by a synthesized review of contextual variables.
Mechanisms of change in family therapy models
Multisystemic therapy Multisystemic therapy (MST) is a home‐based family therapy
approach developed to help youth with serious antisocial behavior and a high risk of
out‐of‐home placement. It draws upon a socio‐ecological framework that empowers
caregivers with resources, skills, and support from the community (Henggeler &
Schaeffer, 2016). In several RCTs of MST, improvements in parenting and family
relations and reductions in associations with deviant peers were found to decrease
delinquency (Huey, Henggeler, Brondino, & Pickrel, 2000) and antisocial behaviors
(e.g., Dekovic, Asscher, Manders, Prins, & van der Laan, 2012) in adolescents. These
broader mechanisms have also been identified in uncontrolled studies (e.g., Tiernan,
Foster, Cunningham, Brennan, & Whitmore, 2015) and qualitative investigations
(e.g., Kaur, Pote, Fox, & Paradisopoulos, 2015) where the therapeutic alliance, fam-
ily functioning, parenting skills, and removing negative peer influences have all been
attributed to sustained positive changes. Several therapist behaviors, including teach-
ing, focusing on strengths, reinforcing statements, problem solving, and dealing
with family needs, increased caregiver engagement and/or positive response (Foster
et al., 2009).
Multidimensional family therapy Multidimensional family therapy (MDFT) is a fam-
ily‐based treatment used particularly with youth substance abuse and antisocial behav-
iors that draws upon developmental‐contextual and dynamic systems frameworks
(Liddle, 2016) to reshape family functioning. MDFT improved parental monitoring,
which decreased adolescent drug use, and overall parenting skills, which decreased
youth symptoms (Henderson, Rowe, Dakof, Hawes, & Liddle, 2009). Interventions
focused on changing family interactions were associated with reduction in drug use
and emotional and behavioral problems (Hogue, Liddle, Dauber, & Samuolis, 2004).
In a task analysis (G. S. Diamond & Liddle, 1999), specific therapist behaviors associ-
ated with defusing negative interactions included actively blocking, diverting, or
addressing and working through negative affect; implanting, evoking, and amplifying
thoughts and feelings that promote constructive dialogue; and creating emotional
treaties among family members (through separate and conjoint sessions).
The therapeutic alliance with both adolescent and parents has been associated with
treatment retention and positive outcomes including decreased drug use and treat-
ment completion in several studies (e.g., Robbins et al., 2006). Specific alliance‐form-
ing behaviors associated with improved adolescent engagement included attending to
the adolescent’s experience, formulating personally meaningful goals, and presenting
one’s self as the adolescent’s ally (G. M. Diamond, Liddle, Hogue, & Dakof, 1999).
Functional family therapy Functional family therapy (FFT) combines systemic and
cognitive‐behavioral theories to address several behavioral problems of youth and their
families by focusing on the function or “payoff” of certain behaviors (Robbins,
Alexander, Turner, & Hollimon, 2016). Studies emphasize improvement in several
family functioning variables (supportive communication, positive interactions, positive
perceptions, parent involvement) as key mechanisms of change in positive outcomes

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(Robbins et al., 2016). Early findings highlighted the importance of early engagement
and motivation mechanisms, which led to a more active “frontloading” approach to
early treatment sessions (Robbins et al., 2016). For instance, early alliance imbalances
(good alliance with parent but not adolescent) were associated with early dropout
(Robbins, Turner, Alexander, & Perez, 2003). Therapist relational skills were more
important than structuring skills in creating change (Alexander, Barton, Schiavo, &
Parsons, 1976). Whereas early family negativity increased risks for dropout, improve-
ments in communication by the end of treatment were associated with positive out-
comes (Alexander et al., 1976). Further, therapist reframing reduced negative
expressions in early sessions (e.g., Robbins, Alexander, & Turner, 2000).
Brief strategic family therapy Brief strategic family therapy (BSFT) integrates struc-
tural and strategic concepts and strategies to change the patterns of family interactions
that allow or encourage problematic adolescent behavior such as drug and alcohol
use, delinquency, association with antisocial peers, and unsafe sexual behaviors
(Horigian, Anderson, & Szapocznik, 2016). Process research indicated that negativ-
ity in family interactions during the first session led to retention problems (Fernandez
& Eyberg, 2009), but families were more likely to engage in treatment if negativity
was reduced through restructuring (Robbins et al., 2000). Early engagement also
required therapists to maintain a balanced alliance with the parent and adolescent;
imbalance led to early dropout (Robbins et al., 2000). Reframing appears to be the
therapist behavior least likely to damage therapists’ alliance with family members
(Robbins et al., 2006). Robbins, Feaster, Horigian, Puccinelli et al. (2011) examined
therapist’s adherence to the model using data from BSFT’s large effectiveness trial by
analyzing four technique domains: therapist joining, tracking and eliciting enact-
ments, reframing, and restructuring. Each domain predicted higher retention.
Whereas joining behaviors often decreased over time (as expected) and restructuring
increased over time, when joining had smaller declines and restructuring had larger
increases, there were better adolescent drug outcomes. Joining was also key to improv-
ing family functioning.
Attachment‐based family therapy Whereas MST, MDFT, FFT, and BSFT focus on
more systemic‐behavioral theories and externalizing symptoms, attachment‐based
family therapy (ABFT) emphasizes a systemic‐experiential/emotional approach for
internalizing symptoms. In ABFT, attachment theory is applied to the treatment of
adolescent depression and suicidal ideation by healing and strengthening the attach-
ment bond between parents and children (G. Diamond, Russon, & Levy, 2016).
Emotional processing by family members over the course of treatment was related to
decreases in psychological symptoms (G. M. Diamond, Shahar, Sabo, & Tsvieli,
2016). Decreases in parents’ psychological control and increases in autonomy grant-
ing led to some improvement in attachment security and depressive symptoms
(Shpigel, Diamond, & Diamond, 2012).
ABFT is made up of five therapeutic tasks (relational reframe, adolescent alliance,
parent alliance, reattachment task, and autonomy promoting), most of which have
been empirically investigated. The relational reframe redefines the goal of treatment
from “fixing the adolescent’s pathology” to repairing and strengthening family attach-
ment relationships (G. Diamond & Siqueland, 1998). Process studies found that
therapists’ use of relational reframing helped parents see the problem relationally,

maintain that relational frame, and decrease their negativity (e.g., G. Diamond,
Siqueland, & Diamond, 2003). Qualitative interviews also indicated that adolescents’
expressions of strong attachment‐related emotions helped parents view the problems
as relational (G. Diamond et al., 2003).
Although there is no current research on the adolescent alliance task, there was a
task analysis done on the parent alliance: across five stages, the therapist (a) expresses
concern and acknowledges the parents’ efforts, (b) explores and empathizes with the
parent regarding personal challenges faced throughout life, (c) focuses on the par-
ent–adolescent relationship by reframing the problem in relational terms, (d) defines
and works on goals and relevant tasks of therapy, particularly around increasing secu-
rity of the parent–adolescent attachment bond, and (e) highlights the parent’s
strengths and abilities to increase their confidence and motivation to move forward in
addressing the adolescent’s challenges (G. Diamond et al., 2003). The quality of this
parent alliance predicted parents’ positive behavior in the subsequent attachment task
(Feder & Diamond, 2016).
The reattachment task helps parents and children engage in conversation to heal
attachment ruptures and increase attachment security. Preliminary support was found
for three stages: (a) adolescent disclosure of emotions and attributions about relevant
events, (b) parent disclosure of their limitations and experiences to increase the ado-
lescent’s understanding, and (c) parent–child dialogue consisting of mature self‐dis-
closure, reciprocity, and forgiveness (G. Diamond et al., 2003). There is currently no
published research on autonomy promoting (parents supporting children in resolving
concerns external to the family), the final task of ABFT. In sum, the process research
on ABFT highlights how addressing emotional processes within and between parent
and adolescent helps adolescents to express their emotions to parents and parents to
respond to them in attachment‐promoting ways.
Summary of the mechanisms of change Key findings from this review emphasize key
mechanisms between SFT and outcome—changes in the family system, parental func-
tioning, and removing the adolescent from negative peer influences. Of course, sev-
eral therapist behaviors and therapeutic processes appear to be invaluable in making
this process happen: developing a positive relationship with both parents and adoles-
cents and balancing the alliance between them, reframing how families view the prob-
lems and the relationship and focusing on strengths, and restructuring those
relationships in order to decrease negativity and foster hope by blocking negative
behavioral patterns, shifting toward deepened emotional connections, promoting
constructive dialogue, and reinforcing better patterns were all generally consistent
processes in engaging families in the process of change, reducing negativity, improv-
ing parental functioning and family system dynamics, and ultimately reducing prob-
lematic adolescent behaviors and symptoms. It is important to note the stark contrast
between the behaviorally oriented (MST, MDFT, FFT, and BSFT) and emotionally
oriented models (ABFT) in how they approach the change process. Amidst their com-
mon factors (active‐directive, balanced alliances, relational reframes, restructuring,
etc.), their diverse ways of achieving therapeutic change are in harmony with their
differential foci on externalizing (behavioral) and internalizing (emotional) symptoms
and problems. We believe therapists working with parents and adolescents need to be
well versed in treating both types of issues and must develop skills in working within
these common patterns and navigating between their unique differences.

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Contexts of change in family therapy models
There are several contextual variables that do influence the likelihood of successful
treatment in adolescent‐focused family therapy. In terms of demographic client fac-
tors, results are mixed. Client race, gender, socioeconomic status, and age generally
did not differentiate successful and unsuccessful cases in MST (Henggeler & Schaeffer,
2016). Both male and female youth responded well to FFT (Baglivio, Jackowski,
Greenwald, & Wolff, 2014). However, communication processes in session were
moderated by family role and therapist gender in FFT (e.g., Newberry, Alexander, &
Turner, 1991). Further, caregiver race, financial hardship, and therapist–caregiver
racial match occasionally moderated the relationship between other therapist and car-
egiver behaviors in MST (Henggeler & Schaeffer, 2016). Indeed, in FFT, alliance
imbalances were found only among Hispanic families, but not white families (Flicker,
Turner, Waldron, Brody, & Ozechowski, 2008), and ethnic match (between therapist
and family) was related to greater reductions in substance use for Hispanic youth only,
not for White youth (Flicker, Waldron, Turner, Brody, & Hops, 2008). Additionally,
addressing cultural and racial/ethnic themes increased adolescent participation in
treatment in MDFT (Jackson‐Gilfort, Liddle, Tejeda, & Dakof, 2001). Hence, in
some cases, differences such as race may be more salient to clients, and therapists who
effectively attend to these contexts may be more successful.
Levels of severity in several factors may also impact the likelihood of success. High
narcissism and callous traits in youth predicted less favorable outcomes in MST
(Manders, Dekovic, Asscher, van der Laan, & Prins, 2013). Families with more severe
conflict and pessimism were the least likely to change in MDFT. Further, negative
peer involvement, such as gang affiliation, was associated with treatment failure (e.g.,
Boxer, Kubik, Ostermann, & Veysey, 2015) and less decline in aggression and delin-
quency (Ryan et al., 2013).
Treatment adherence has also been explored as a contextual variable and was asso-
ciated with better outcomes in internalizing and externalizing symptoms, family
cohesion, and conflict in MDFT (e.g., Hogue, Dauber, Samuolis, & Liddle, 2006)
and higher retention in BSFT (Robbins, Feaster, Horigian, Puccinelli et al., 2011).
Further, a minimal dose of FFT (seven to eight or more sessions) predicted good
clinical outcomes, though quick movement through the process increased the posi-
tive effects (e.g., Robbins et al., 2003). Taken together, when contextual factors are
accounted for in family therapy, they nearly always provide a better understanding of
the conditions in which treatment is successful providing guidance toward those
areas that may need special focus and attention for successful therapy to occur,
including race and ethnicity, gender, individual psychopathology, and severity of
family conflict.
Mechanisms of change in couple therapy models
Behaviorally focused couple therapies Traditional behavioral couple therapy (TBCT)
is rooted in behaviorism and emphasizes reinforcement principles and skill‐building
exercises for couples (Fischer, Baucom, & Cohen, 2016). Integrative behavioral cou-
ple therapy (IBCT) maintained some of TBCT’s skill‐building focus but introduced
“acceptance” in order to address the difficulty couples had changing around polar-
ized issues (Roddy, Nowlan, Doss, & Christensen, 2016). A separate evolution of

behavioral models includes cognitive‐behavioral (Fischer et al., 2016) and mindful-
ness‐based approaches; however, processes of change within these approaches have
never been empirically investigated to our knowledge. While TBCT has substantial
outcome research support, the only substantial research on processes of change was
evaluated as part of a large comparative RCT of TBCT and IBCT—hence we simul-
taneously reviewed the process research on both models as both shared many simi-
larities. It is important to note, however, that while therapist behaviors and change
events were not explored, the pathways of change for particular variables were.
Self‐report measures were first analyzed (Doss, Thum, Sevier, Atkins, & Christensen,
2005). In both TBCT and IBCT, improvements in the frequency of a partner’s self‐
reported target, positive, and negative behaviors during the first half of therapy were
related to early increases in satisfaction. During the second half of therapy, these asso-
ciations washed out and rates of improvement were no different between the models.
Wives’ early acceptance of husband’s positive behaviors lead to early satisfaction and
husband’s early acceptance of wives’ negative behaviors lead to early satisfaction.
Increases in positive communication and decreases in negative communication both
predicted changes in relationship adjustment in the expected directions for both mod-
els. Spouses in TBCT, however, experienced greater changes in their partner’s behav-
ior during the first half of therapy, and the association was stronger between changes
and satisfaction. Spouses in IBCT experienced greater improvements in acceptance of
partner’s target behaviors across the entire course of treatment. Acceptance improve-
ment in IBCT increased relationship satisfaction during the first half of treatment for
husbands and the second half of treatment for wives (Doss et al., 2005).
Observational analyses also assessed how changes in communication were related to
changes in relationship satisfaction (K. J. Baucom, Sevier, Eldridge, Doss, &
Christensen, 2011; Sevier, Eldridge, Jones, Doss, & Christensen, 2008). In both
TBCT and IBCT, increased problem solving and positivity during problem discus-
sions were associated with greater relationship satisfaction for both spouses at post-
treatment and, for wives only, at 2‐ and 5‐year follow‐up, whereas negativity during
discussions was related to lower satisfaction for both spouses at posttreatment.
Withdrawal behavior during conversations about personal problems were related to
decreased satisfaction for wives, but when husbands decreased withdrawal behavior,
wives experienced greater satisfaction at 2‐year follow‐up. IBCT couples experienced
fewer improvements in communication than TBCT couples but demonstrated better
maintenance of their improvements. IBCT and TBCT demonstrated different pat-
terns of change in observed behaviors: IBCT couples had an initial increase in nega-
tive communication and decrease in positive communication in the first half, but
positive and negative communication improved in the second half, whereas TBCT
couples experienced early improvement in both during the first half but deterioration
during the second half of treatment (Sevier, Atkins, Doss, & Christensen, 2015).
In sum, early changes in self‐reported behavior, communication, and acceptance
were important predictors of early increases of relationship satisfaction in both IBCT
and TBCT. Further, observed communication behavior during treatment was important
in understanding relationship adjustment following treatment for both models. While
these changes occurred in both models, several differences between them highlight their
core emphases. TBCT couples experienced more behavioral change early in treat-
ment, and these behavioral changes were more important for TBCT couples. IBCT
couples, on the other hand, experienced more acceptance throughout therapy, which

Anderson
was also more important for these couples in predicting adjustment. It would almost
appear as if couples “buy in” to the model’s premise and evaluate their adjustment
according to how well they “fall in line” with the model’s posited values. Also note
that while more significant behavioral changes occurred in TBCT, IBCT was better at
maintaining their changes in the long term.
Emotionally focused couple therapies Emotionally focused couple therapy (EFT) is
rooted in attachment theory and draws primarily upon systemic and experiential
principles (Wiebe & Johnson, 2016). EFT was co‐developed by Greenberg and
Johnson (1988) and diverged into two models with theoretical and practical differ-
ences: emotionally focused couple therapy (EFT) S. M. Johnson, 2004) and emo-
tion‐focused therapy for couples (EFT‐C) (Greenberg & Goldman, 2008).
Therapist’s “emotional presence” (i.e., an awareness of and responsiveness to clients’
emotions) and therapist’s ability to access and deepen emotional experiences in EFT
were associated with greater warmth behaviors and emotional experiencing by clients
and successful change events (e.g., Furrow, Edwards, Choi, & Bradley, 2012).
Several studies demonstrated that greater emotional experiencing (i.e., feeling,
exploring, and organizing emotions in session) by couples was strongly associated
with more positive outcomes (e.g., Greenman & Johnson, 2013; S. M. Johnson &
Greenberg, 1988; Makinen & Johnson, 2006). EFT‐C research found client’s
expression of underlying attachment‐related emotions (e.g., fear) related to positive
post‐session ratings and overall treatment outcomes (Greenberg, Ford, Alden, &
Johnson, 1993; McKinnon & Greenberg, 2013).
EFT also works to improve interactions between partners in session through enact-
ments and affiliative responding (disclosure of emotions and sensitive responses;
Greenberg et al., 1993; Tilley & Palmer, 2013). Two specific enactments or “key
change events” are withdrawer reengagement and pursuer softening. Lee, Spengler,
Mitchell, Spengler, and Spiker’s (2017) task analysis of withdrawer reengagement
found several processes that lead the withdrawn partner to become more connected:
(a) aiding the withdrawer to identify and experience their attachment‐related fears
and needs in session, (b) facilitating the expression of those fears and accompanying
needs with their partner, and (c) helping the partner to respond in a supportive man-
ner. Bradley and Furrow’s (2004) task analysis of pursuer softening likewise found
similar processes that lead the pursuer to shift from being overly hostile/critical to
asking for reassurance or comfort from a more vulnerable position (softening): (a)
facilitating the pursuer’s emotional experience of underlying attachment fears and
needs, (b) directing the sharing of those fears and needs to their partner, and (c) sup-
porting the partner to respond with support and reassurance. The pursuer‐softening
event occurred with “successful” couples but not with “unsuccessful” couples (S. M.
Johnson & Greenberg, 1988), and the completion of this change event increased
relationship satisfaction and decreased attachment insecurities for couples (e.g.,
Dalgleish et al., 2015).
Specific interventions used in the pursuer and withdrawer tasks included heighten-
ing emotion, evocative questioning and responding, heightening present and chang-
ing positions, empathic conjecture/interpretation, reframing, validation, and
restructuring and shaping interactions (Bradley & Furrow, 2004; Lee et al., 2017). In
a follow‐up study, Bradley and Furrow (2007) identified common therapist missteps
that interfered with the pursuer‐softening change event: an absence of an attachment

lens when working with emotions, only talking about rather than feeling attachment
emotions, an avoidance of attachment‐related fears, a lack of differentiating internal
view of self and view of other, and not having the pursuer actually “reach” for the
other through disclosing their fears and needs. This softening process for couples
occurs then as therapists intervene in ways to help both partners to experience and
express their attachment‐related emotions and to respond productively to the others’
vulnerable expressions.
EFT also aims to heal attachment‐related emotional injuries, defined as “a per-
ceived abandonment, betrayal, or breach of trust in a critical moment of need for
support expected of attachment figures” (Makinen & Johnson, 2006, p. 1055). The
therapeutic process developed for this healing is referred to as the Attachment Injury
Resolution Model (AIRM) (S. M. Johnson, Makinen, & Millikin, 2001). The most
salient steps of the model have been identified (i.e., injured partner expressing vulner-
able emotions, offending partner acknowledging the impact and expressing remorse,
injured partner accepting the apology and expressing attachment needs, and offend-
ing partner responding in an affiliative manner) and validated through several task
analyses. The AIRM has been shown to effectively discriminate between resolved and
unresolved couples as evidenced by greater emotional experiencing, more affiliative
responding in sessions, and more positive overall outcomes (e.g., improvements in
attachment security), which were sustained over time (e.g., Makinen & Johnson,
2006; Zuccarini, Johnson, Dalgleish, & Makinen, 2013). Interventions for this task
included empathic reflection, validation, empathic conjecture, evocative responding,
and heightening and the systemic interventions of track and reflect, reframe, and
restructuring and shaping interactions. Researchers of EFT‐C also developed a pro-
cess model for resolving emotional injuries with many steps similar to the AIRM
(Meneses & Greenberg, 2011). The model consists of three main markers: the offend-
ing partner’s expression of shame, the injured partner’s acceptance of the shame, and
in‐session expression of forgiveness. Applying the model has promoted forgiveness
and decreases in marital distress (Meneses & Greenberg, 2014).
Lastly, Swank and Wittenborn (2013) examined the process by which an EFT ther-
apist worked to repair a rupture in the therapist–client relationship. They delineated
the process in steps for the therapist: acknowledging the rupture, exploring the cli-
ent’s emotional experience of the rupture, apologizing and owning responsibility for
the rupture, checking in with the other partner and facilitating empathy for the part-
ner’s emotions related to the rupture, addressing any concerns related to the rupture,
and expressing appreciation for the client’s openness and normalizing the process of
rupture and repair.
Contexts of change in couple therapy models
Studies on IBCT and TBCT found more established couples (married more than
18 years) were more likely to improve (satisfaction and stability) than less established
couples (married less than 10
years) at posttreatment and 2‐ and 5‐year follow‐up
(Atkins, Berns et al., 2005; B. R. Baucom, Atkins, Simpson, & Christensen, 2009; B.
R. Baucom, Atkins, Rowe, Doss, & Christensen, 2014). Higher levels of commit-
ment and greater desires for closeness were associated with less separation likelihood.
Early research on TBCT consistently found that more severely distressed couples were
less likely to improve in couple therapy (Snyder, Mangrum, & Wills, 1993)—a finding

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also replicated in EFT research (S. M. Johnson & Talitman, 1997). In addition to
couple traits, individual traits matter a great deal. In a study of behavioral and insight‐
oriented therapies, couples with negative marital affect and depressive symptomatol-
ogy at intake were more likely to be distressed at termination and continue to be
distressed or divorced 4 years after treatment (Snyder et al., 1993). Several studies in
EFT found that certain client qualities at intake such as attachment quality, willing-
ness to self‐disclose, emotional control, and emotional awareness were unrelated to
emotional experiencing in sessions and treatment outcomes (e.g., Dalgleish, Johnson,
Burgess Moser, Wiebe, & Tasca, 2015; S. M. Johnson & Talitman, 1997). One con-
trasting study, however, showed that greater attachment anxiety and emotional con-
trol at intake predicted greater improvements in relationship quality (Dalgleish,
Johnson, Burgess Moser, Lafontaine et al., 2015).
The co‐occurrence of and interplay between individual and couple‐related factors
are critical in understanding the process of change in couple therapy, and several natu-
ralistic studies of general couple therapy clearly illuminate this. High rates of coexist-
ing issues (anxiety, depression, and IPV) meant couples would begin treatment with
lower relationship satisfaction; however, contrary to previous findings, these factors
did not seem to inhibit successful outcomes (Rowe, Doss, Hsueh, Libet, & Mitchell,
2011). If anything, couples reporting low rates of relationship satisfaction experi-
enced greater change in therapy (Doss et al., 2012). Further, improvements in com-
munication, closeness, and psychological distress mediated the effect of treatment on
subsequent relationship satisfaction and improvement in relationship satisfaction
mediated the effect of treatment on psychological distress (Doss, Mitchell, Georgia,
Biesen, & Rowe, 2015). Other data indicated that relationship and individual func-
tioning improved most dramatically during the first four sessions of therapy and then
stabilized during the next four sessions and relationship adjustment predicted changes
in individual functioning only for men, but the inverse was not found for either sex
(Knobloch‐Fedders, Pinsof, & Haase, 2015). These results indicate that there are
consistent associations between individual and relationship functioning variables that
influence one another and the change process at pretreatment, during treatment, and
after treatment, but future research is clearly needed to better clarify and contextual-
ize these pathways of change.
The role of special circumstances needs to also be more closely inspected. For
example, those couples who experienced infidelity and revealed the affair (as opposed
to keeping it secret) prior to treatment showed greater acceleration of improvement
than those without an infidelity history (Atkins, Eldridge, Baucom, & Christensen,
2005) and demonstrated no significant differences in outcomes at posttreatment and
5‐year follow‐up (Marin, Christensen, & Atkins, 2014). On the other hand, infidelity
couples fared significantly worse when the secret affair was not disclosed before or
during treatment (Marin et al., 2014). Similar outcomes were also found between
couples with little physical aggression and couples with no aggression prior to treat-
ment (Simpson, Atkins, Gattis, & Christensen, 2008). Therapist characteristics should
also gain more attention in couple therapy as one study on EFT demonstrated that
securely attached novice therapists delivered simulated EFT at higher fidelity than
insecure therapists, particularly with addressing attachment‐related needs and emo-
tions (Wittenborn, 2012).
In essence, when these contextual factors are not taken into account, we can easily
fall into the trap of overextending results about how these models work. The severity

of couple distress, individual symptoms and characteristics, domestic violence, infidel-
ity and therapist characteristics deserve special attention when applying the methods
of these approaches. Finally, other factors clearly deserve more attention in couple
therapy including mixed agendas and divorce proneness as the models heretofore
discussed often work under the assumption that both couples have some desires to
improve their relationships (Doherty, 2011).
Making the Case for Integrative Process Research in SFT
Many now acknowledge the reality that most therapists prefer to practice from an
integrative and client‐centered approach (Lebow, 2014; Norcross, Karpiak, &
Santoro, 2005) that is less rooted in the dogma of various models. Although some
therapists have a home model they work from, they recognize the need for clinical
flexibility and incorporate strategies from other approaches for particular issues. The
movement toward research on integrative practice has been encouraged by a new
focus on identifying key principles of change that reach therapeutic outcomes
(Castonguay & Beutler, 2006; Castonguay, Eubanks, Goldfried, Muran, & Lutz,
2015). This trend is growing in SFT as well (Lebow, 2014). Process research is very
well suited to this approach, but often process findings are model specific. We believe
an analysis of the key mechanisms of change that either cut across the contexts of vari-
ous models (common factors) or may be uniquely suited for specific contexts (unique
factors) provide a more useful map or guide for therapists to apply an integrative and
principle‐based approach to their work. In our view it is useful to explore both unique
and common factors that produce change—in fact, unique and common factors can-
not exist without the other—common elements depend on specific treatments and
unique variables exist in the context of common factors (McAleavey & Castonguay,
2015). While the following review gives attention to those factors that are generally
common across systemic treatments, we acknowledge there may be unique ways in
which these factors are applied, which future research will need to clarify.
Systemic alliance
The single most frequently studied process variable in SFT is the therapeutic alliance.
Bordin (1979) articulated the most widely accepted understanding of the alliance,
describing it as consisting of the bond between the therapist and client as well as the
agreement about the goals and tasks of therapy. Pinsof and others (Friedlander,
Escudero, & Heatherington, 2006; Pinsof, 1994, 1995; Pinsof & Catherall, 1986)
expanded this definition to account for the greater complexity that arises when mul-
tiple clients are participating in therapy. Four unique aspects of this expanded thera-
peutic alliance are particularly salient for understanding this complexity. First, when
working with a system, the therapist must develop an alliance with each member of
the system and with the group as a whole (between‐system alliance). Second, multiple
between‐system alliances (e.g., alliance between parents and therapist and children
and therapist) present the strong possibility for differing strengths or valences of these
alliances (split or unbalanced alliances). Third, while in individual therapy, the rela-
tionship between the client and therapist is paramount, when the couple or family

Anderson
relationship is considered a primary mechanism of change, the quality of the working
relationship between family members becomes particularly important. This within‐
system alliance (Pinsof, 1994) or shared sense of purpose (Friedlander et al., 2006)
reflects the family members’ agreement on the goals and tasks of therapy as well as
their joint investment in the therapy process. Finally, unlike individual therapy, what
is said in the therapy room is witnessed by other family members and can have signifi-
cant repercussions outside of therapy. Friedlander and colleagues (2006) identified
the relative sense of safety in the system as another unique element of this expanded
therapeutic alliance. The process research on the alliance can be divided into the rela-
tionship between alliance and “big O” outcomes, “little o” outcomes, and research
that examines how the alliance develops over time.
Systemic alliance and “big O” outcomes The alliance is a robust predictor of therapy
outcomes in SFT with effect sizes that are similar to or larger than those found in
individual treatment (d = 0.622, medium effect size; Friedlander, Escudero, Welmers‐
van de Poll, & Heatherington, 2018). In a recent meta‐analysis, Friedlander and col-
leagues (2018) found that the alliance–outcome effect was the same regardless of
client presenting problem or modality (couple vs. family treatment); however, alli-
ance–outcome correlations were higher when the targeted children were younger,
when there were more adult males in the sample, and when clients were in therapy
voluntarily. Additionally, while the alliance–outcome correlation was significant for all
models of therapy, it was strongest for cognitive‐behavioral models and lowest for
structural/functional and multisystemic models of therapy.
Two themes from this meta‐analysis stand out. First, of the various alliance factors,
the within‐system alliance had the strongest association with outcome, suggesting
that the working relationship between partners and family members is particularly
relevant to change in SFT. This is not surprising given the focus most systemic models
give to family relationships in producing change, but highlights the need for systemic
therapies to develop alliance‐building and repair strategies that target this systemic
component of the alliance. Second, men’s alliances in relational therapy were impor-
tant. Studies on the alliance among heterosexual couples consistently demonstrate
that the male partner’s alliance is particularly important in predicting positive out-
comes for both himself and his partner (e.g., Bartle‐Haring, Glebova, Gangamma,
Grafsky, & Delaney, 2012; Glebova et al., 2011). It is unclear why this is, but Anker,
Owen, Duncan, and Sparks (2010) have suggested that a strong alliance with the
male partner is essential to overcome the culturally promoted resistance he may feel
to participate in therapy.
While there are some exceptions (e.g., Flicker, Turner, et al., 2008; Muñiz de la
Peña, Friedlander, & Escudero, 2009), the majority of research has concluded that
the lower the quality of alliance, the greater the likelihood that the couple or family
will end therapy prematurely (e.g., Anderson, Tambling, Yorgason, & Rackham,
2018; Bartle‐Haring et al., 2012; Knobloch‐Fedders, Pinsof, & Mann, 2004; Robbins
et al., 2003). Early alliance development appears to be particularly important for pre-
venting dropout (e.g., Thompson, Bender, Lantry, & Flynn, 2007).
Although the overall quality of the alliance is an important predictor of dropout,
the prevalence and severity of split alliances appear to be just as, if not, more impor-
tant. Split alliances occur in between 32 and 43% of couples in treatment and appear
to grow more common as therapy progresses (e.g., Knobloch‐Fedders et al., 2004).

Friedlander and colleagues (2018) meta‐analysis identified a stronger effect size for
the association between split alliances and outcome than for the general alliance–out-
come relationship. Individual studies have shown that severe split alliances are seen
more often in cases of dropout than in those with positive outcomes (e.g., Friedlander,
Lambert, Escudero, & Cragun, 2008). The relationship between alliance and drop-
out varies, however, depending on how split alliances are operationalized (Bartle‐
Haring et al., 2012) and what relationship the split occurs in (Robbins et al., 2003).
For example, Robbins et al. (2003) found that the greater the difference between the
adolescent and the father’s rating of alliance in therapy, the greater the potential for
dropout. The same was not true for other splits in the system. More needs to be done
to understand which alliances are most important under what circumstances to help
clinicians navigate this complexity.
Systemic alliance and “little o” outcomes Several studies have examined the relation-
ship between the alliance and immediate session outcome. Multiple studies have
found that the alliance, particularly the task and within‐system components, is associ-
ated with greater session depth and smoothness (e.g., Kivlighan, 2007). For example,
Friedlander, Kivlighan, and Shaffer (2012) found that when parents rated the alliance
higher, they were more likely to experience the session as deeper and more valuable.
Parent–therapist alliance has also been associated with parent behaviors that promote
attachment with their depressed adolescent (Feder & Diamond, 2016). The safety
that the family feels in treatment appears to be particularly important, with greater
safety leading to stronger within‐system alliances that, in turn, led to early symptom
improvement (Muñiz de la Peña et al., 2009). Taken together, these studies demon-
strate that there is a relationship between the perceived value of the session and alli-
ance quality and suggest significant complexity that needs to be understood.
Development of the systemic alliance over time A growing body of literature has exam-
ined how the alliance develops over time. At the most simplistic level, research has
identified several pretreatment predictors of a strong alliance. These include differen-
tiation of self (e.g., Knerr et al., 2011), individual distress (e.g., Anderson & Johnson,
2010), relationship satisfaction (e.g., Anderson & Johnson, 2010; S. M. Johnson &
Talitman, 1997; Knerr & Bartle‐Herring, 2010; Knobloch‐Fedders et al., 2004), and
quality of attachment of both client and therapist (e.g., L. N. Johnson, Ketring, &
Espino, 2018; Miller et al., 2015; Wittenborn, 2012; Yusof & Carpenter, 2016).
More complex longitudinal research has also begun examining the trajectory of
the alliance in therapy. While some have found that alliance is fairly stable by session
two and remains stable over the early sessions of therapy (Glebova et al., 2011),
others have found that alliance quality changes over time (e.g., Escudero, Friedlander,
Varela, & Abascal, 2008). This appears to be particularly true of the within‐system
alliance and safety within the system components of the alliance (e.g., Escudero
et al., 2008). As Anker and colleagues (2010) have reported, it is likely that the
development of the alliance is dependent on several moderating variables. Their
sample was characterized by three distinct patterns of alliance development. Those
with the best outcomes had high initial alliances that continued to increase over
therapy. Two additional groups emerged: those with moderate alliances that con-
tinue to increase over time and a group with lower initial alliances that remain flat
throughout treatment (Anker et al., 2010). Future research focusing on moderators

Anderson
of alliance trajectory will be an important area of further study to first understand
how alliance changes throughout treatment and to then use this information to
provide feedback to therapists to improve outcomes.
In methodological contrast to these multi‐session longitudinal studies, a few
small‐sample studies have begun to examine differences in therapist and client alli-
ance‐promoting behavior within sessions of good and poor outcome cases. Much of
this research has focused on therapy with adolescents and their parents and has
shown that therapists who attend to the adolescent’s experience helped the adoles-
cent establish meaningful goals, oriented the clients to therapy, promoted the ado-
lescent’s autonomy, and rolled with client resistance were able to successful develop
and strengthen alliances over time (G. M. Diamond et al., 1999; Higham,
Friedlander, Escudero, & Diamond, 2012; Muñiz de la Peña, Friedlander, Escudero,
& Heatherington, 2012; Thompson et al., 2007). How clients and therapists
respond to each other in session can either promote or detract from alliance devel-
opment. In successful cases, clients respond with their own alliance behaviors within
3
min of the therapist’s use of an alliance‐promoting behavior (Friedlander et al.,
2008); and when clients exhibit negative behaviors, therapists in successful cases
respond with alliance‐strengthening behaviors more often than in unsuccessful cases
(Sheehan & Friedlander, 2015). How family members respond to each other in
treatment also impacts the alliance, with the limited research showing that partner
negativity inhibits the development of husbands’ alliances (Thomas, Werner‐Wilson,
& Murphy, 2005).
As therapy progresses, particularly with the complexity involved in systemic ther-
apy, ruptures in the alliance are inevitable. Indeed, Pinsof (1995) predicted that
ruptures would be a normal part of treatment and that a stronger overall alliance
would be the natural result of repairing these ruptures. The individual alliance lit-
erature has long recognized the importance of this alliance rupture and repair pro-
cess (Safran, Muran, & Eubanks‐Carter, 2011). While this literature has grown,
little is known in the couple and family therapy field. In part, this is due to the
difficulty operationalizing a rupture. Is the alliance ruptured when the therapist
maintains a strong relationship with the parents but a ruptured alliance with the
adolescent? The defining characteristics of ruptures in systemic therapy appear to
be the same as individual treatment: withdrawal or confrontation (Escudero,
Boogmans, Loots, & Friedlander, 2012); however these ruptures occur not only
with the therapist but between family members as well. While few systemic studies
of the alliance have used the term rupture, some have begun to examine this phe-
nomenon. For example, Friedlander, Heatherington, Johnson, and Skowron
(1994) examined client disengagement among a small sample of clients that subse-
quently reengaged and those that were not able to reengage. In cases that were
able to successfully reengage, five elements were present: being able to gain insight
about the disengagement, communicating about the impasse, acknowledging the
thoughts and feelings of others, and developing a new construction about the
impasse. In an unpublished dissertation, Goldsmith (2012) found that these rup-
tures occur frequently and, as predicted, that their resolution is associated with
improved outcomes. Future research is needed to further elaborate what ruptures
look like in systemic therapy and the therapist and client behaviors that lead to suc-
cessful repairs.

Client system engagement and retention
Highly related to successful alliance building is the process of engagement and reten-
tion. SFT involves encouraging participation of family members who might be
involved in the problem, keeping families a part of the process, and facilitating their
active engagement in sessions (Heatherington, Friedlander, Diamond, Escudero, &
Pinsof, 2015). Engaging whole families has always set SFT apart, but it can be quite
complicated to do so, and there is much debate today about when this is most impor-
tant (Lebow, 2014). Either way, some process research has examined the benefits of
engaging the identified client and family members as well as what leads to successful
engagement and retention.
Client system engagement has been of greater concern in adolescent‐focused ESTs
because of the high‐risk retention difficulty; early treatment engagement was impor-
tant for FFT to be successful (Robbins et al., 2016). Reducing negativity through
restructuring and balanced alliances were important in initial studies of BSFT (Robbins
et al., 2000), and a recent large study of BSFT showed that adherence to the treat-
ment manual, rapport with the family, attention to resistance, and a facilitation of
parent involvement, safety, and discussing the shared contributions of family members
all lead to retention (Robbins, Feaster, Horigian, Puccinelli et al., 2011; Sheehan &
Friedlander, 2015). Attending to the adolescent’s experience, formulating personally
meaningful goals, and presenting one’s self as the adolescent’s ally were all important
in adolescent engagement in MDFT (G. M. Diamond et al., 1999).
One naturalistic study (Higham et al., 2012) explored factors that contributed to a
resistant adolescent either shifting or not shifting from negative to positive engage-
ment during session. Positive shifts were more likely when therapists structured thera-
peutic conversation, fostered autonomy, built systemic awareness, rolled with
resistance, and understood the adolescent’s subjective experience; parental support
was also important. Further, a recent review of the literature on retention processes in
SFT identified six important therapist‐generated conditions for retention of families
in therapy: conveying understanding and support, demonstrating knowledge and
expertise, conveying a genuine desire to help, providing clarity about the family ther-
apy process, conveying hope that problems can be resolved, and creating a safe envi-
ronment (McAdams III et al., 2018). With the difficulty of even initially getting
whole families into therapy (Breunlin & Jacobsen, 2014), it seems that engagement
and retention are incredibly important processes of change to pay attention to in SFT.
Systemic reframing
Reframing is perhaps the most common systemic intervention. It involves helping
families redefine their view of the problem in more systemic terms (i.e., A does not
cause B, but A and B are mutually influencing). Usually couples or families initially
locate a problem within one individual (my spouse is lazy or my child throws tan-
trums). Reframing seeks to alter this view and point the family toward interactional
processes that are involved in the problem. Doing so interrupts blaming, deepens
understanding, and provides new solutions.
There are, however, many ways to activate these shifts in perspective. For instance,
results from a task analysis of a narrative‐constructivist approach (Coulehan et al.,

Anderson
1998), which generally relies on questioning to help shift perspectives, indicated three
recursive change processes facilitated by the therapist: (a) family members described
their respective viewpoints of the problem, (b) these viewpoints shifted through affec-
tive responses, and (c) felt sense of hope for change. Effective therapist behaviors
included directing the session to keep focus and including each family member, seek-
ing information about interpersonal events and family dynamics, exploring and rein-
terpreting negative attributions, highlighting strengths, redefining the problem, and
inviting the expression of feelings. Other models using a similar, but often more
direct, style of highlighting patterns in the system likewise find good results including
reduced negative expressions early in sessions, more favorable responses by adoles-
cents (FFT; e.g., Robbins et al., 2000), protections to the therapeutic alliance (BSFT;
Robbins et al., 2006), higher retention (BSFT; Robbins, Feaster, Horigian, Rohrbaugh
et al., 2011), and decreases in parental negativity and increases in parents viewing the
problem in more interpersonal terms (ABFT; e.g., G. Diamond et al., 2003). It seems
that all family therapy models, in one way or another (e.g., circular questioning or
direct statements), seek to highlight interactional patterns of one kind or another
(e.g., negative narratives and dialogue or negatively reinforcing behaviors). While
there are different ways of going about this, it seems clear that systemic reframing is
an important part of the pathway to successful outcomes in SFT.
Systemic enactments
Enactments can be broadly defined as therapist‐facilitated interactions between clients
and are commonly used to assess or modify family dynamics. Enactments can be
employed independently and as key interventions in many prominent models of SFT
(e.g., Hogue et al., 2006; Tilley & Palmer, 2013). There is ample empirical support for
enactments as an effective intervention in promoting change, and it has been argued
that they be considered a “best practice” in SFT, representing a necessary ingredient in
effective relational therapy (e.g., Butler & Wampler, 1999; G. M. Diamond, Shahar
et al., 2016; Friedlander, Wildman, Heatherington, & Skowron, 1994; Gardner &
Butler, 2009; Heatherington et al., 2015; Shields et al., 1991).
Several empirical studies investigating enactments identified three stages of thera-
pist behaviors: initiation, facilitation, and closing (Davis & Butler, 2004; M. P. Nichols
& Fellenberg, 2000). At the stage of initiation, therapists introduce goals and roles
(i.e., clients speak directly to one another), specify the topic for the interaction, and
establish the structure of the enactment. For facilitating effective enactments, thera-
pists avoid interrupting family members and encourage continued and productive
dialogue between family members, particularly about attachment‐based emotion. To
close an enactment, therapists recall the goals of the enactment, evaluate the process
and outcome of the interaction, and invite commitments relevant to the enactment.
Family members who were most effective during enactments demonstrated willing-
ness to engage with each other, spoke about their own feelings without attacking or
defending, and experienced a noticeable productive shift in their interactional pattern
by the end of the enactment. Butler, Davis, and Seedall (2008) found that beginning
therapists demonstrated less proficiency around establishing goals, roles, and topics in
the initiation phase, intervening to facilitate emotional and/or attachment expression
and listening in the intervention phase, and evaluating the goals, quality of interac-
tion, and commitments to change in the evaluation phase.

As to specific therapist behaviors associated with productive enactments, the use of
“proxy voice” (therapist speaking for a client) increased the likelihood of softening
(e.g., sharing primary affect) and decreased the likelihood of withdrawal or negativity
(Seedall & Butler, 2006). In addition, a process‐analytic study found that therapist’s
directiveness, structuring, and working with emotion during enactments were related
to both more positive and less negative interactions between partners (Woolley,
Wampler, & Davis, 2012). Examining successful enactments in family therapy,
researchers developed a measure of therapist behaviors, the Family Therapy Enactment
Rating Scale (Allen‐Eckert, Fong, Nichols, Watson, & Liddle, 2001). Their discov-
ery‐oriented study supported certain therapist actions during successful enactments
including directing family members to talk to one another, encouraging family mem-
bers to discuss an affect‐laden topic, promoting continued engagement between fam-
ily members during the enactment, and summarizing the interaction and praising
family members at the conclusion of the enactment. Process studies within EFT,
ABFT, and MDFT also highlight various therapeutic processes within enactments as
previously discussed (G. S. Diamond & Liddle, 1999; G. M. Diamond, Shahar et al.,
2016; Greenman & Johnson, 2013).
Butler and Gardner (2003) proposed a developmental model for facilitating enact-
ments to guide the amount of structure and type of instructions given for an enact-
ment according to the reactivity of a couple and their progress in therapy. Andersson,
Butler, and Seedall (2006) conducted an evaluation study whereby couples at various
stages of therapy experienced two types of enactments—a structured, safe‐guarded
enactment and a free‐form, coached enactment. Through follow‐up interviews with
the couples, they found that adjusting the structure of enactments according to cou-
ples’ presenting problems and level of reactivity improved outcomes. The interviews
also reaffirmed the role of the therapeutic relationship and certain therapist behaviors
in promoting such outcomes.
Given that research on the structure and process of enactments is “reasonably com-
plete” (Gardner & Butler, 2009, p. 321), future research could further test the vari-
ous models of enactments and their specific components among different populations
(e.g., Seedall & Butler, 2008) and through experimental designs.
Other Systemic Change Processes Needed for Future Research
There are several factors that will need greater attention in future change process
research. There are many questions about when certain methods of systemic interven-
tion might be most appropriate. For instance, when should family therapists focus on
creating cognitive, emotional, behavioral, or insight‐oriented shifts between and
within family members. Is this just a preference of style/model and is it irrelevant
which process one uses, or are there moderating factors including the cultural back-
ground of the client system, the personality of each member, or specific issues?
Although some process research exists on some of these variables, they have usually
been investigated only within a model that specifically targets that domain—hence, it
can be quite difficult to examine the differential effects of these modes of practice.
Larger naturalistic studies of therapists of varying styles or orientations may be useful
in beginning to examine how and when these approaches might be most effective.

Anderson
Therapist characteristics have been given a lot of attention in individual therapy
(Baldwin & Imel, 2013) including observable traits (e.g., age, sex, ethnicity), observ-
able states (e.g., training), inferred traits (e.g., personality style), and inferred states
(e.g., therapeutic relationship). These are also important variables in SFT and there
are likely therapist characteristics that may be uniquely suited for SFT that could be
explored in future research including the therapist’s ability to handle conflict and
emotional intensity, to think systemically and notice patterns, etc. Individual therapy
has moved somewhat away from specific characteristics of therapists in specific studies
and more toward an emphasis on identifying individual therapist’s own effectiveness
following a foundation in feedback informed therapy (Prescott, Maeschalck, & Miller,
2017). It may only be a matter of time before SFT more fully takes up this same trend
and we begin identifying effective systemic therapists and whether deliberate practice
similarly makes them more effective.
There is a greater need to integrate therapist and client characteristics into process
research at individual and systemic levels. Individual client factors include client
demographic variables, pathology, clinical characteristics, perceptions of therapy, and
constructive activity (Bobart & Wade, 2013). SFT process research should keep in
mind the powerful influence of individuals in systemic processes. Nevertheless, we
need greater development of client system characteristics that should be explored. For
instance, we can begin investigating other dyadic processes beyond the classic pur-
suer–withdrawer process including those outlined by Tomm, St. George, Wulff, and
Strong’s (2014) IPscope diagnostic approach. Triadic processes, such as triangulation
or unbalanced parental hierarchies, are also key client system characteristics and pro-
cesses that could be actively explored in SFT process research.
There is a greater need to explore group‐based trajectories in SFT. Many studies in
individual therapy have found different experiences of progress including those who
make change, those who deteriorate, and those who remain stagnant (Bobart &
Wade, 2013). This does not translate so simply into SFT. Do you measure the indi-
vidual change of each partner or family member as well as the combined change of the
entire family? What happens when one individual in the system makes dramatic
changes and the other does not? Although this is certainly complex, it is possible—
and would be extremely beneficial to the field—to identify the characteristics of cli-
ents and therapists that are associated with various trajectories of change in couple and
family therapy.
While a quantitative investigation of client and therapist factors is important, we
should not underestimate the powerful role of qualitative investigations describing
effective change processes. It is important to determine what is most helpful in creat-
ing change from the client’s perspective. Often we rely too heavily on our own theories
and not enough upon the consumer’s point of view in clinical research. As a demon-
stration of how useful this can be, Chenail and colleagues conducted an impressive
qualitative metasynthesis of 49 articles focused on clients’ experiences of SFT (Chenail
et al., 2012). Their findings indicated that clients view therapy positively when they
experience a sense of connection between their preconceptions of therapy and what
they actually experience in therapy, when therapeutic processes are connected to
desired outcomes and changes in their lives, and when therapists create constructive
balances of the needs and goals between family members (Chenail et al., 2012).

Findings such as these can further aid the field delineating the common and unique
factors of effective SFT.
Finally, SFT has progressively moved toward a greater multicultural and sociopoliti-
cal orientation (McDowell, Knudson‐Martin, & Bermudez, 2018) and with that
comes a need for more attention to the social and cultural characteristics of our cli-
ents. Fortunately, many of our models have been used among diverse and vulnerable
populations, and some of our process research has investigated these key contexts. We
believe, however, that more can and must be done as we progressively become even
more diverse and pluralistic and sensitive to the needs of the underserved. Future
research should be hard‐pressed to capture these dimensions and the best practices for
diverse families.
Applying Process Research in SFT Training and Practice
The current emphasis in SFT training privileges teaching the schools of family therapy
alongside common factors (Karam, Blow, Sprenkle, & Davis, 2015) and then encour-
aging students to develop a personal model of change that integrates concepts of the
various schools that are compatible with the student’s own worldviews (Nelson &
Prior, 2003; Simon, 2006). We see some drawbacks to this approach. While there
certainly are common factors that are important to the change process, unique factors
are also an important part of the pathway to change, especially for unique problems
and contexts (McAleavey & Castonguay, 2015). The process research reviewed here
indicates to us a both/and approach that privileges skills around common and unique
processes that may go neglected by model‐ or therapist‐centered training. Clinical
wisdom suggests that for certain populations, there simply are better and worse ways
to proceed. Many in the field of clinical psychology recognize the limitations of sin-
gular treatment models and find burgeoning evidence of the advantages of integrative
approaches that tailor methods to the unique situation of their clients (Castonguay
et al., 2015). A training framework that teaches students to choose a model that
works through common factors does not take the full breadth of process research
findings into account.
We call upon training programs to actively integrate the implications of the pro-
cess research reviewed here into training programs. To be able to address this call,
however, it seems to us that the best course of action will include a major paradigm
shift in training. We believe that our clientele is at the center of practice and train-
ing and that students should develop skills in tailoring treatment to the unique
needs of any given client system. Some in clinical psychology have advocated a
principle‐based approach that draws upon research evidence of the mechanisms
and contexts of change for various problems and populations and trains students in
becoming skilled around those treatment principles rather than in selecting and
becoming good at a specific model (Castonguay & Beutler, 2006; Castonguay
et al., 2015). For instance, in a study of clinical psychology training, clients whose
student‐therapists followed and were supervised according to a principle‐based
approach showed greater therapeutic gains compared with those who received

Anderson
supervision as usual (Stein, 2017). We have documented several principles of
change throughout that we believe deserve greater privilege and emphasis in train-
ing programs. This does not replace the need for theory—the why behind an
enactment sometimes provides the motive and rationale to leverage it successfully
in therapy. We find that students, however, worry more about whether structural
therapy fits for them or not than whether they have learned effective skills in using
enactments. In essence, we believe a principle‐based approach will be much more
useful for training and practice than a model‐based approach.
Beyond this paradigm shift, there are several ways students can be encouraged to
draw upon current process research findings. First, students should begin collecting
data on their own therapeutic processes by tracking progress among their own client
systems (Lappan, Shamoon, & Blow, 2018). Supervisors can help students process
these data and find implications for how they can improve their skills in developing
systemic alliances and creating systemic change. Second, when teaching the schools of
family therapy, it is important to educate students on the, sometimes, lack of process
research on them as singular models, but the wide breadth of process research on
integrative systematic programs that have used them—pointing out which processes
have been validated in which specific contexts. Third, it is not difficult to assign stu-
dents readings of process research studies. The nice thing about these studies is that
students find them more relevant than other articles they might read during their
training. For example, when teaching students how to develop skills in enactments,
educators should point students to some key articles including structural family ther-
apy’s 25 different ways of doing enactments (M. Nichols & Tafuri, 2013) and what
made some more successful than others (M. P. Nichols & Fellenberg, 2000). This is
a powerful teaching tool. Students can also be encouraged to identify process‐specific
research on their own. Often students will find research that supports an entire model
of therapy, but this gives little guidance on research‐based skills or principles that are
more relevant to integrative and principle‐based training and practice.
Conclusion
The field of SFT research is progressively growing in a direction of identifying core
mechanisms and contexts of change that can explain the effectiveness of this way of
practice. Many of the various schools and programs of practice reviewed here outlined
many of their therapeutic processes that predict outcomes and the conditions for suc-
cessful change. We have identified some of the key mechanisms of change that seem to
cut across most models of SFT and the research that have supported them including a
systemic alliance, systemic engagement and retention, systemic reframing, and systemic
enactments. We have pointed out several areas for future research in SFT including the
need for greater multicultural considerations. Finally, we have identified several training
implications from this breadth of research. When we can begin to integrate and synthe-
size the key findings from process research, we are able to start formulating a useful map
for the successful practice of SFT that practitioners from all walks of life can learn from
and apply to their own practices. While we know that SFT can be quite effective, the
research reviewed in this chapter provides a foundation for ongoing endeavors to clarify
and solidify those mechanisms and contexts for successful work in our field.

Note
1 We did not review parent training programs because they lacked any substantial “process”
research. These programs, however, have received immense research support in the “out-
come” literature.
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