Marianne Welmers

Chapter 2 24 the start, middle or end of therapy, or at multiple moments, emphasizing that alliance is an ongoingprocess rather thanafixedstateconcept (Horvath, 2006; Karver &Carporino, 2010). Inaddition, somestudiesusealliancechangescores to investigatewhether the improvement of allianceduring the therapyprocess influences treatment outcome (e.g., Bachler et al., 2016; Keeley et al., 2011). The relevance of this second type of alliance is illustrated by a study on alliance in adolescent psychotherapy, demonstrating that alliance change scores explain more variance in treatment outcome compared to single moment measures or an average of multiple single moment measures (Owen, Miller, Seidell, & Chow, 2016). A third type of alliance refers to so-called ‘split’ or unbalanced alliances, and addresses the systemic aspect of alliance in family-involved treatment. Multiple family members formalliances with the therapist, whichmight differ in strength. When one family member has a better alliance with the therapist than other family members (i.e., alliances with the therapist are unbalanced between family members), this is generally referred to as a ‘split alliance’. Some studies have investigated whether these split alliances affect treatment outcome by subtracting family members’ single alliance scores and correlating these discrepancy scores with treatment outcome. When discrepancy scores are investigated, a negative correlation with treatment outcome is expected (i.e., higher levels of unbalance lead to less favorable treatment outcomes) instead of a positive correlation, as is the general hypothesis in research on the level of individual- or family alliance and outcome. Moderators of the Alliance – Outcome Association Theassociationbetweenallianceandoutcomecanbemoderatedbyseveral factors. Several methodological aspects of studies might have a moderating effect, as has been reported inmeta-analyses on alliance and outcome in youth and adult psychotherapy (Horvath et al., 2011; McLeod, 2011; Shirk &Karver, 2003; Shirk, Karver, &Brown, 2011). First, it is important to investigate whether study quality moderates the alliance – outcome association: when higher qualitystudies indicateastronger effect, thismight bean indicationof the robustness of the association. Second, timingof alliancemeasurement can be an importantmoderator. Alliance might be a predictor of outcome early in treatment, underlining the importance of alliance as a facilitator of successful therapy. On the other hand, meta-analyses in youth psychotherapy (McLeod, 2011; Shirk & Karver, 2003) and adult psychotherapy (Horvath et al., 2011) have indicated that alliancemight bemore predictive of outcomewhen assessed in a later stage of treatment, as it may need some time to build. It might furthermore be of influence whose perspective on alliance as well as on outcome ismeasured (parent, youth, therapist or observer). Especially in family-involved treatment, with multiple family members involved, it is important to know what perspective is most predictive of successful treatment. Meta-analyses on alliance in youth psychotherapy