Marianne Welmers

General Discussion 135 CHAPTER 6 correlations that might be of theoretical importance. We found that a greater imbalance in observed early-treatment alliances was associated with less externalizing and total youth behavior problems at follow up. Over the course of treatment this association changed to the opposite direction: at mid-treatment a greater imbalance was associated with more externalizing and total youth problems, although the association was small and not significant. One conclusion was that perhaps the process of balancing family members’ differing alliances during treatment, rather than the lack of difference in alliances itself, may contribute to improvement of children’s behavior problems and deserves further investigation. Furthermore, higher levels of mid-treatment shared sense of purpose were moderately, but not significantly, associated with the decrease of youth internalizing behavior problems 18 months post-treatment. This indicates that a stronger shared sense of purpose within the family at mid-treatment may have a clinical significance in reducing internalizing child behavior problems that warrants further exploration. Reflection on Main Findings Working alliance as predictor of better treatment outcomes A key finding, resulting from the meta-analytic review in Chapter 2, is that building strong working alliances with families in treatment for a variety of youth problems contributes to positive treatment outcome. This finding is consistent with other recent meta-analytic findings, indicating that the alliance is a predictor of positive outcomes in child and adolescent psychotherapy (Karver et al., 2018; Roest et al., 2021b), adult psychotherapy (Flückiger et al., 2018), and couple and family therapy (Friedlander et al., 2018). The finding is also consistent with two recent studies on the alliance – outcome association in home-based family interventions (Bachler et al., 2016; De Greef et al., 2018b). The overall effect size of r = .18 in our meta-analysis was smaller as compared to results of recent meta-analyses on the alliance-outcome association in adult psychotherapy ( r = .28; Flückiger et al., 2018), couple and family therapy ( r = .30; Friedlander et al., 2018), and adolescent mental health treatment ( r = .29; Murphy & Hutton, 2018), but comparable with two other recent meta-analyses in youth psychotherapy ( r = .20; Karver et al., 2018; r = .16; Roest al., 2021b). Taken together, these findings to some extent imply a smaller contribution of the alliance for treatment focused on youth problems as compared to adult and family problems, although findings regarding themagnitude of the effect size in treatment addressing youth problems remain equivocal. Nevertheless, these findings do suggest a significant contribution of the alliance to family treatment for youth problems, and underline the importance of building strong alliances with families when providing (home-based) family treatment.