Marianne Welmers

Alliance and Treatment Outcome 57 CHAPTER 2 Most of the significant moderating variables were sample characteristics, with different moderators for the three separate meta-analyses. The association between level of alliance and treatment outcome was significantly moderated by average age of youth in the sample, demonstrating stronger correlations when youths were younger. This is in line with findings of McLeod (2011), and Shirk and Karver (2003) showing that in youth psychotherapy associations between alliance and outcome were stronger for younger children compared to adolescents. However, it should be noted that in the present study variance in average age of youth in study samples was small, with the lowest average age of 10.6 and the highest average age of 16.1. Most study samples comprised only families with adolescents, some samples comprised adolescents as well as younger children, and no studies were included with families with children in primary school age only. It is unclear whether our study findings can be generalized to families receiving therapy or treatment due to concerns regardingmuch younger children. In familieswith younger children, the role of the child in therapymight not be as active as compared to older youth, resulting perhaps in lower correlations between youth alliance and outcome and higher correlations between parent alliance and outcome. Another moderating sample characteristic in the association between level of alliance and treatment outcomewas referral source, showingstronger correlationsbetweenallianceand outcome for clientswhowere help-seeking or recruited for the study compared to samples withmandated clients or a combination of mandated and help-seeking clients. This finding was replicated in the meta-analysis on alliance change scores and treatment outcome. Two recent studies compared alliance processes in family therapy between voluntary and involuntary clients. These studies revealed that initial between-group differences in the emotional bond with the therapist and the within-family alliance did disappear after four sessions of therapy (Sotero et al., 2016; 2017). Between-group differences in agreement on therapeutic goals and tasks, however, remained after the fourth session. Thus, the difference in the alliance – outcome association between self-referred and involuntary clients might be explained by both timing and dimension of alliance measure. However, no research has yet been published on the relation between specific aspects of alliance processes with mandated clients in relation to treatment outcome. Furthermore, in the present meta-analysis only one study could be included with mandated clients only. Five other included studies reported on samples of both mandated and help-seeking clients, with no reports of specific effect sizes for both groups. It was surprising that no moderating effects were found for problem type or treatment model in the association between level of alliance and outcome. Several meta-analyses have demonstrated moderating effects for problem type (McLeod, 2011; Shirk & Karver, 2003; Shirk, Karver, & Brown, 2011). In the present study, the sample of included studies