Marianne Welmers

Alliance and Treatment Outcome 25 CHAPTER 2 either suggest that the parents’ or the therapists’ perspective on the alliance is most predictive of outcome (McLeod, 2011; Shirk & Karver, 2003) and that children’s reports on the alliance show very little variability (Shirk & Karver, 2003). In addition, alliance seems to bemost predictive of therapeutic outcome as perceived by either the parent (McLeod, 2011) or the therapist (Shirk & Karver, 2003) when compared to youth or observer reported outcome. A methodological feature specific for studies on alliance in family-involved treatment is whether the alliance is measured at an individual (e.g., parent-therapist, youth-therapist) or family level (the alliance between the therapist and the family as awhole) using instruments specifically designed for family interventions. These instruments not only investigate individual alliances between family members and therapist, but additionally address the within group or group with therapist aspects of alliance typical of family interventions. The moderating effect of type of alliance in family therapy is illustrated in a study by Escudero et al. (2008), in which the within-family alliance was correlatedmore strongly with outcome than the individual alliances. However, not all studies on alliance in family-involved treatment use instruments designed to measure family-aspects of the alliance as well as individual alliances. As pointed out by McLeod (2011), the correlation between alliance and outcome in family-involved treatment might be stronger when the alliance measure is designed to investigate alliance-processes typical of working with multiple family members. Aside from methodological features of studies, several treatment aspects could moderate the effect of alliance on outcome. First, treatment models differ in the extent to which alliance building aspects of treatment are specified. Some treatment models explicitly describe alliance building stages of treatment (ABFT, Feder & Diamond, 2016) or therapeutic practices to buildmultiple alliances (FFT, Sexton & Alexander, 2004; MDFT, Liddle, 2002). For other treatment models, such as family-based CBT (Freeman et al., 2003), no specific alliance building stages or techniques are described. For the latter, the correlation between alliance and outcome might be smaller than for treatment models with a strong emphasis on alliance building practices. Also, referral to treatment was shown to have a moderating effect in a meta-analytic review on alliance in youth psychotherapy in a way that correlations between alliance and outcome were found to be stronger for help-seeking youth than for youth receiving mandated treatment (McLeod, 2011). Another moderating treatment aspect might be the setting in which treatment is conducted. When treatment is (partially) home-based, the therapist enters the home environment of the family. Effectiveness of the treatment might therefore be more dependent on the degree to which the family feels at ease with and trusts the therapist.