Marianne Welmers

A Systemic Perspective on Alliances and their Relation to Outcome 113 CHAPTER 5 positively impact treatment outcome. To our knowledge, only three studies investigated the effects of within-family differences in alliance on treatment outcomes in terms of improvement of child functioning or symptom distress. Forsberg et al. (2014) found no effect of observed parent-child and mother-father alliance differences on recovery of AnorexiaNervosa in a sampleof 38adolescents receiving family-based treatment. Likewise, Glebova et al. (2018) found no effect of similarity in parent and youth emotional bonds with the therapist on families’ treatment retention nor on therapists’ and families’ perceptions of treatment success at the end of treatment in a sample of 164 parent-youth dyads receiving Multisystemic Therapy (MST). The authors of the latter study reason that in family treatment formats with mainly conjoint treatment sessions, a balance in family members’ strength of the alliance might be more important as compared to treatment formats with a primary focus on caregivers for example. It should also be noted that Glebova et al. (2018) only investigated the effect of discrepancies between family members in emotional bonds, not in goal- or task-aspects of the alliance. In another studywith 156 families receivingAlliance Empowerment Family Therapy (AEFT), differences in alliances between the (maltreated) child or adolescent and the caregiver were studied. Results showed that sessionswith split allianceswere reported as less successful, and that familieswithworse treatment outcome had more sessions with split alliances (Escudero et al., 2021). In a recent meta-analytic study on alliance and outcome of family treatment for youth problems, five of the before-mentioned studies investigating unbalanced or split alliances were included in a separate meta-analysis on the effect of unbalanced or split alliances on treatment retentionandother outcome (Welmers – vandePoll et al., 2018). Theoverall effect was small and not significant. Friedlander et al. (2018) meta-analytically examined the effect of unbalanced or split alliances in couple and family therapy. They extended the previous meta-analysis with one study on couple therapy outcomes and one unpublished family therapy study, and found a significant moderate effect size, indicating that unbalanced or split alliances predict less favorable treatment outcomes in terms of retention vs. drop- out or symptom reduction. In both meta-analyses, the number of included studies was small, and given this small body of evidence authors of both meta-analyses point to the importance of further investigating the effect of unbalanced alliances on family treatment outcome. The present study aims to address this plea by investigating the association between unbalanced family members’ alliances and improvement of youth behavior problems after receiving home based family treatment for youth problems. Shared Sense of Purpose within the Family The secondsystemic aspect of alliancewe aimto investigate in this study is thewithin-family alliance, or sharedsenseof purpose. Inconjoint family treatment, outcome isnot onlyaffected by family members’ differing individual alliances with the therapist, but also by the extent to