Marianne Welmers

Chapter 1 12 Optimizing Home-based Family Treatment: Alliance as a Key Factor Although several studies support the effectiveness of HBFT programs (Bachler et al., 2016; Barth et al., 2007; De Greef et al., 2018b; Lay et al., 2001; Veerman & De Meyer, 2015; Veerman et al., 2005; Yorgason et al., 2005), positive outcomes are not a given. A recent meta-analysis synthesized results of 50 studies on effectiveness of various HBFT programs for families experiencing complex andmultiple problems (Assen et al., 2020). Study findings revealedamoderatedecrease inchildren’s emotional andbehavioral problems and stressful experiences after receiving HBFT, but also indicated significant heterogeneity between children and interventions inoutcomes, and inmany cases considerableproblems remained at treatment termination. Considering these results, identifying factors in the treatment process that enhance treatment outcomeseems vital inoptimizingHBFT, andmaywell serve the interests of families receiving home-based care. Surprisingly, however, generic HBFT services have undergone relatively little empirical process research (De Greef et al., 2018; Sexton et al., 2014). One factor thatmayplayan important role inpositive treatment outcome is the therapeuticor workingalliance. Thispan-theoretical concept refers to the therapeutic relationshipbetween therapist and client, consisting of an emotional bond and agreement on what should be the central goals and tasks of treatment (Bordin, 1979; Elvins & Green, 2008). The role of the working alliance has been studied for decades in numerous forms of psychotherapy, and the current bodyof researchconvincingly indicates itscontribution topositiveoutcomeof youth, adult and family treatment (Flückiger et al., 2018; Friedlander et al., 2018; Murphy & Hutton, 2018). Moreover, of all known factors related to treatment success, thealliance is considered one of the largest contributors (Norcross & Lambert, 2019). However, given its specific andheterogeneous context, resultsof studiesonalliance inother forms of treatment cannot readily be generalized to the context of HBFT. Although a handful of studies confirm the predictive value of alliance for HBFT effects on youth and parent symptomdistress (Johnson et al., 2002; 2006), parent and family functioning (DeGreef et al., 2018b; Johnson et al., 2006), or more general evaluations of treatment success (Bachler et al., 2016; De Greef et al., 2018b), the role of working alliance in this specific context – like in the broader field of generic youth and systemic family care – remains largely understudied. As a result, important questions about the process of building multiple interacting alliances with different family members and the association of alliances with treatment outcome remain largely unanswered. The current dissertation aims at addressing these questions by investigating the dynamic process of building alliances with families receiving home-based family treatment, and the association between alliance and treatment outcome.