Marianne Welmers

General Discussion 139 CHAPTER 6 The second finding regarding unbalanced alliances contrasts findings of both meta- analyses: the explorative study in Chapter 5 indicated that a greater imbalance in family members’ early treatment observed alliances was associated with more positive treatment outcome in terms of youth behavior problems 18 months after treatment. However, when alliances were measured two months later the association was negative (yet small and not significant), giving rise for the premise that it may be the process of balancing familymembers’ differing alliances during treatment – rather than the difference in alliances itself – that is key in enhancing treatment outcomes. Another explanation for this unexpected finding could be that larger alliance differences between familymembers during the starting phase of treatment may be amarker of problematic family functioning and interaction. To illustrate, previous research has shown that larger informant discrepancies in reporting on parenting and child disruptive behavior were associated with problem severity (De los Reyes & Kazdin, 2006; Moens et al., 2018). In the present study sample, problematic family functioning and interaction may be reflected in family members’ divergent attitudes towards treatment and the therapist. Following this line of reasoning, especially these families with problematic family functioningmay benefit most from treatment (see for example also Van Aar et al., 2019). As the treatment progresses, the family’s functioning is likely to improve, which in turn may result in smaller alliance discrepancies, as was the case in the present study sample. Nevertheless, an important conclusion is that the body of research on the process and effect of unbalanced alliances in family treatment is still small and yields equivocal results, underlining the importance of further research. Within-family Alliance: The Importance of a Shared Sense of Purpose An important strength of the current dissertation is that it was – to my knowledge – the first to examine the within-family alliance in the context of home-based family treatment. Following Friedlander et al. (2006), this systemic alliance concept was referred to as shared sense of purposewithin the family (SSP) , reflecting familymembers’ alignment and collaboration on shared family goals. Several findings indicate that enhancing the family’s shared sense of purpose is likely to promote positive treatment outcome of systemic family treatment, including home-based family treatment. In the meta-analysis (Chapter 2), the overall effect size for systemic alliance including SSP was significant ( r = .21), and it was slightly, but not significantly, higher than the overall effect size of individual parent or youth alliance. However, the number of included studies with a systemic measure of alliance was small. A more recent meta-analysis on the alliance-outcome association in couple and family therapy indicated that systemic alliance aspects, such as the family’s SSP, were a significantly stronger predictor of positive outcome than individual alliances, even if multiple family members’ alliances were averaged or added to measure a family unit of alliance (Friedlander et al., 2018).