This process–outcome study was conducted within a naturalistic setting at the Family Unit, Modum Bad, Norway. The aim of the study was threefold:
1) To evaluate the Family Unit’s treatment program by assessing the participants’ degree of mental and relational distress from intake to discharge and changes in distress taking place during treatment.
2) To investigate the predictive relationship of a) therapists’ assessments of patients’ histories of childhood trauma on patient-reported outcome and b) therapists’ assessments of childhood trauma and its association with patient-reported alliance and how it relates to outcome.
3) Apply dyadic analyses (Kenny et al., 2020) as a method of analyses to investigate actor– partner effects related to a) how the actor’s (i.e., the individual) alliance to the therapist predicts his or her relationship satisfaction, b) how the actor’s alliance to the therapist predicts his or her partner’s relationship satisfaction, c) how the actor’s relationship satisfaction predicts his or her alliance to the therapist, and d) how the actor’s relationship satisfaction predicts his or her partner’s alliance to the therapist.
In addition, while relevant for internal use in evaluating the Family Unit’s treatment program, the findings are also considered useful for clinicians and researchers in other couple and family treatment settings. To our knowledge, no similar study using such a range of research methods has been conducted. In Paper 1, where we examined the predictive associations between childhood trauma and outcome, we found that having a history of childhood trauma predicted poorer relational outcomes compared with patients without such experiences. Paper 2, which aimed to further explore these findings using qualitative methods, highlighted the relational difficulties that couples in therapy experience. These difficulties were prominent both regarding the relationship between spouses and between the individual patient and the therapist. These findings made us, as researchers, aware that we had to apply statistical methods that considered the reciprocal nature of couple– and individual– therapist relationships. Further examination of the literature led us to learn how multilevel modeling (MLM; Curran & Bauer, 2011) could be adapted to analyze how couples change by applying a dyadic level of analysis (i.e., actor–partner effects; Kenny et al., 2020). Our dyadic analysis, which was presented in Paper 3, further illuminated nuances of the interplay between alliances and relationship satisfaction: Male spouses’ alliance with the therapist is paramount for the female spouses’ perceived relationship satisfaction the following week.
In conclusion, our study has contributed to the literature by identifying and exploring how couples with histories of trauma experience relational challenges in therapy and how such challenges are related to poorer outcomes. Furthermore, the application of dyadic analyses as conceptualized within the actor–partner interdependence model (APIM; Kenny et al., 2020) presented novel results pertaining to working alliances. Our findings strengthened our conviction that mixed-method research designs with the application of dyadic analysis are necessary when studying complex relational phenomena. Our position on the benefits of dyadic analysis is supported by the recommendations of Friedlander et al. (2021). Contrary to more traditional means of analysis, which allow the identification of change at the level of the individual, dyadic analysis has the benefit of furthering our understanding of how systems change. The application of dyadic analysis on longitudinal data lets us examine how systems change across time and thus has the potential to facilitate the development of more precise interventions, thereby improving outcomes for a wider range of patients, including those that may have been defined as non-responders or otherwise treatment resistant. Finally, we may infer that as a program evaluation, this study presents satisfactory results for the 2018–2020 cohort of patients whom attended therapy at the Family Unit, demonstrating significant positive changes during the treatment period.