Marianne Welmers

Therapists’ Contributions to the Alliance 85 CHAPTER 3 Second, despite the vital importance of systemic aspects of the alliance in conjoint family treatment, such as a shared purpose among familymembers and a sense of safety during treatment (Friedlander et al., 2019), we had no data on family members’ and therapists’ experience of these systemic aspects. This was due to the fact that we only had self- and therapist reported data from the WAI measure, designed for individual therapy, and the fact that measures of therapists’ observed shared sense of purpose behaviors had to be excluded from this study due to insufficient reliability. Regarding differences between family members in their alliance with the therapist – another systemic complexity in building alliances in family treatment – the number of included youth in our sample did not provide sufficient statistic power to differentiate between therapists’ contributions to alliances with parents and alliances with youth. We did however include multiple family members as informant of the alliance, controlled for family role (parent vs. youth) in our models, and included observations of therapists’ safety behaviors, and thus to some extent accounted for systemic alliance complexity. A final limitation is that we only investigated therapists’ unilateral contributions to the alliance, and not the interaction between therapists’ and family members’ contributions. This might imply that there is such a thing as a universal set of therapist characteristics that are best for every client or family. However, not only differences between therapists in their alliances with clients impact treatment outcome, alliance differences between clients treated by the same therapist can also be of substantial influence (Baldwin, & Imel, 2013). Future research could benefit from explaining why a given therapist has above average alliances with some families and family members, but below average alliances with other families and family members. This involves investigating families’ and family members’ characteristics contributing to the alliance (e.g. De Greef et al, 2018a; Sotero et al., 2017), as well as the effect of interaction or ‘match’ between therapist and family members’ characteristics and behaviors (e.g. Friedlander et al., 2008a). Despite its limitations, to our knowledge our study was the first to investigate therapists’ contributions to the alliance in family treatment including therapist personality and years of clinical experience. Although therapists’ observed in-session alliance building behaviors have been studied before in family therapy (Diamond et al., 1999; Escudero et al., 2012; Friedlander et al., 2014; Muñiz de la Peña et al., 2012), our study adds to this body of knowledge by studying a larger sample, and providing empirical evidence for the association between therapist behaviors and family members’ as well therapists’ reports of the alliance. The multi-informant character strengthens the robustness of our study findings. Another strength is the (short-term) longitudinal design, investigating the alliance as a process that evolves during treatment rather than as a static phenomenon.