Marianne Welmers

Chapter 2 56 and youth psychotherapy have consistently reported stronger correlations between alliance measured during late-treatment compared to alliance measured during early or mid-treatment (Horvath et al., 2011, McLeod, 2011, Shirk & Karver, 2003). However, none of these studies reported on multiple alliance measures averaged or added as a category for timing of alliance measure. If we take into account that our meta-analysis on alliance-change scores and treatment outcome showed a marginally significant larger effect size compared to the association between level of alliance and outcome, our findings underline the importance of viewing the alliance as a dynamic process rather than a static, single-moment entity. No moderating effects were found in any of our analyses for type of alliance informant (youth, parent or observer) or alliance construct. These findings are in line with the findings from the meta-analytic review of Shirk, Karver, and Brown (2011), that did not showmoderating effects for any characteristics of the alliance measure. Also, Horvath et al. (2011) found no moderating effect for alliance rater in the association between alliance and outcome in individual adult psychotherapy. However, other meta analytic reviews have reported larger effect sizes for therapist rated alliance compared to other sources of alliance measurement (Shirk & Karver, 2003), or for parent rated alliance compared to other sources of alliance (McLeod, 2011). This might indicate that no consistent conclusion can yet be drawn about the role of alliance source in the alliance-outcome association. Contrary to our expectations, in the association between level of alliance and outcome we found no moderating effect for type of alliance informant (youth, parent or observer), type of alliance (youth-therapist, parent- therapist or family alliance), construct of alliance (bond, goal, task, within-family), or alliance measures designed specifically for family therapy in order to capture systemic aspects of the alliance. Previous studies that found a smaller or less significant effect on treatment outcome for alliance in family-involved treatment compared to individual treatment have underlined the importance of studying alliance in family therapy with instruments that capture systemic aspects of alliance typical of working with multiple family members (Lange et al., in prep.; McLeod, 2011). The rationale behind this point of view is that alliance instruments designed for family therapy might lead to a better understanding of the alliance-outcome association in family-involved treatment. However, research on alliance and outcome using specific family therapy alliance measures is still scarce, and in the present study only four independent samples using a specific family therapy measure of the alliance could be included in the meta-analysis on level of alliance and outcome. Furthermore, out of these four study samples, three samples contained only a small number of families ( n < 50).