Marianne Welmers

Chapter 2 22 The process of building and maintaining an emotional bond and agreement on tasks and goals raises several complexities in working with families. In family-involved treatment, the therapist simultaneously develops multiple alliances with family members who are in treatment together, but who differ in their characters, needs, and treatment expectations (Kindsvatter & Lara, 2012; Rait, 2000). For instance, in a study on alliance and treatment outcome in home based family therapy by Johnson, Wright, and Ketring (2002) the correlation between alliance and outcome was stronger for fathers than for mothers. For fathers, the agreement with the therapist about treatment goals was more predictive of treatment outcome than the agreement on tasks and the emotional bond, whereas for mothers agreement on tasks was relatively more predictive of treatment effectiveness. In addition, research showed that treatment effectiveness can be reduced when the therapist develops a stronger alliance with one family member than with the other: these unbalanced or so called ‘split’ alliances increase the risk of treatment drop out (Flicker, Turner, Waldron, Brody, & Ozechowski, 2008; Robbins et al., 2003). Anothercomplicatingaspectofbuildingandmaintainingalliances infamily-involvedtreatment is that each person’s alliance with the therapist is observed and influenced by the other participating family members (Friedlander, Escudero, & Heatherington, 2006; Kindsvatter & Lara, 2012). Theseobservationsmight cause feelingsof unsafetyor anxiety, sincewhat issaid during a session can have repercussions outside therapy sessions. For example, a teenage son who tells the therapist about a relapse in drug abuse with his parents present, might be worriedabout gettingpunishedat home for this relapse. Thus, the therapist needs toprovide guidelinesor discussbasic rulesof safety andconfidentiality inorder togainconfidence and trust from all participating family members (Friedlander et al., 2006). A third aspect of alliance specific to family-involved treatment is that treatment outcome is not only affectedbymultiple individual alliances between therapist and familymembers, but also by the alliance with family as a whole (Escudero, Friedlander, Varela, & Abascal, 2008; Friedlander, Lambert, & Muñiz de la Peña, 2008; Kindsvatter & Lara, 2012). When family members perceive themselves as a group collaborating to improve family functioning and achieve other therapeutic goals, treatment is more likely to be effective. Therefore, family therapists must leverage different views on problems and solutions within the family and try to bring about a shared sense of common family goals by for example emphasizing shared values and experiences (Escudero et al., 2008; Friedlander et al., 2006; Rait, 2000). Perhaps because of these complexities in alliance processes specific to family-involved treatment, research on alliance in this field emerged later and received far less attention than research on alliance in individual psychotherapy. In the 1980s, Pinsof and Catherall (1986) applied Bordin’s definition of alliance to three interpersonal levels by measuring