Marianne Welmers

Alliance and Treatment Outcome 23 CHAPTER 2 bonds, tasks, and goals for three relationships: self-with-therapist, other-with-therapist, and group-with therapist. This approach was elaborated on by Pinsof (1994) when he added the within-family alliance , namely, the extent to which family members collaborate on goals and tasks and experience an emotional bond with each other during therapy. Symonds and Horvath (2004) defined this concept as allegiance. Friedlander, Escudero, andHeatherington (2006) elaborated on Bordin’s definition of alliance as well as family therapy-specific alliance processes, such as allegiance, by distinguishing four domains of alliance in family therapy: (a) emotional connection to the therapist, (b) engagement in the therapy, (c) shared sense of purpose within the family (similar to Pinsof’s within-family alliance ), and (d) safety within the therapeutic system. The two latter domains are said to be unique to conjoint family therapy. To date, only one meta-analytic review on the association between alliance and outcome in family-involved treatment has been published (Friedlander et al., 2011). This study investigated the alliance-outcome correlation in 16 family therapy studies and 8 couple therapy studies. The result of the analysis was an average weighted effect size of r = .24 for the family therapy studies, demonstrating that higher levels of alliance are associated withmore positive treatment outcome. This overall effect size is comparable to the effect size inmeta-analyses on alliance and outcome in individual adult and youth psychotherapy (Horvath, Del Re, Flückiger, & Symonds, 2011; Shirk, Karver, & Brown, 2011). Although Friedlander et al.’s (2011) meta-analysis provides a valuable test of the association between alliance and outcome in family therapy, the study also underlines the importance of further meta-analytical research on alliance in family-involved treatment for two reasons. First, the study included only 16 family therapy studies published until 2008. Since then, scientific attention for alliance processes in family-involved treatment research has burgeoned, resulting in an increase of studies on the subject. Second, the study reported significant variability in the correlation between alliance and outcome. This is not surprising, because the studies that were included in the meta-analysis showed a large heterogeneity with regard to alliance measures and other methodological aspects. This variety within and between studies was dealt with by collapsing several alliance measures (e.g., multiple types of alliance, informants, measurement instruments and measurement moments) into one effect size per study. No distinction wasmade between different types of alliance processes and no moderator analyses were conducted. Therefore, the reported variability between studies remained unexplained. Different types of Alliance Processes in Family Involved Treatment In research on the association between alliance and outcome in family-involved treatment, different types of alliance processes can be distinguished. A first type of alliance is the more traditional fixed moment measure of the level of alliance. Alliance can be measured at