Marianne Welmers

Chapter 5 126 Discussion In thepresent studywe investigated theassociationbetween (a) familymembers’ unbalanced alliances and the family’s shared sense of purpose, and (b) youth behavior problems 18 monthsafter endinghome-based family treatment. Contrastingour hypotheses, our findings indicate that unbalancedobservedearly-treatment alliances lead tomore favorable treatment outcome in terms of externalizing and – to some extent – total youth behavior problems at followup. This is a remarkablefinding that contrasts the scarcebody of previous researchon alliancedifferencesand family treatment outcomeshowingnoeffect of unbalancedalliances (Forsberget al., 2014;Glebovaet al., 2018) oranegativeeffect (Escuderoet al., 2021).However, across treatment the association changed to the opposite direction: at mid-treatment a greater imbalance was related to more externalizing and total youth problems at follow-up, although this association was small and not significant. Thus, a plausible explanation seems that larger early treatment alliancedifferencesoffermore roomfor balancingalliancesduring treatment, whichmay in turn enhance treatment outcome. This hypothesis is supportedby a studyofBartle-Haringet al. (2012),whofoundthat in their sampleof couples receivingtherapy, an increase in congruence between partners in their alliance with the therapist predicted treatment success. In another study, Escudero et al. (2021) found that a larger number of sessions with split alliances was predictive of less favorable treatment outcome in a sample of families receiving therapy because of serious child maltreatment. Both studies underline the relevance of further research on the effect of trajectories in unbalanced alliances over the course of treatment. Differences in observer-rated alliances weremore strongly associated with improvement of youth behavior problems as compared to differences in therapist- or self-reported alliances. This suggests that the observer’s perception of the alliance may be a more important perspective to signal alliance differences as compared to the perception of familymembers and therapists. Perhaps the lack of personal involvement in the treatment process helps observers to gain a more objective perspective on the therapist’s alliances with family members. On the other hand, it could also be argued that the observer’s perspective reflects a different rather than a more objective perspective on the alliance. Horvath (2006) distinguishes between the intrapersonal and the interpersonal construction of the alliance. Observers’measuresof theallianceoperationalize the interpersonal dimensionof thealliance, reflected in tangiblebehavior in the interpersonal exchange. Therapists’ and familymembers’ self-reports operationalize the intra-personal dimensionof the alliance, which encompasses the individual thoughts, feelings and opinions in relation to the other person and to the relationshipwith theother person. Following this lineof reasoning, our studyfindings indicate that adisbalance in the interpersonal behavioral dimensionof familymembers’ allianceswith the therapist seems most essential in marking clinical significance.