This article reviews meta-analytic evidence for the alliance-outcome relation in couple and family therapy (CFT), with implications for clinical practice. We begin by describing the unique features of CFT alliances and their measurement, followed by two case descriptions. We explain that due to the systemic context of CFT, each patient's personal alliance with the therapist affects and is affected by other family members' levels of collaboration. Because family members often seek help when they are in conflict with one another, "split" alliances are common, as are problematic within-system alliances, defined as the degree to which family members agree on the nature of their problems and value participating in therapy together to achieve shared goals. In our meta-analysis of 48 studies with 40 independent samples, we used a three-level random effects model (Ns ϭ 2,568 families, 1,545 couples, and 491 effect sizes) and found r ϭ .297. In another analysis with seven independent samples and 31 effect sizes, the split allianceoutcome association was also significant, r ϭ .316, indicating that the more split or unbalanced the alliance, the poorer the outcome. Moderator analyses showed that alliance-outcome associations did not differ for couple versus family therapy, but correlations were significantly stronger in samples with younger problem children, older adults, proportionally more male youth and adults, and when the families voluntarily sought help (as compared with involuntary or mandated families). The article concludes with research-informed strategies for building and sustaining strong systemic alliances in CFT. Clinical Impact StatementQuestion: This article describes the unique aspects of the therapeutic alliance in couple and family therapy, measures of the alliance that are most often used in research on this topic, and the patient characteristics that most clearly contribute to a strong alliance. Findings: In a meta-analysis of 48 therapy studies, we found a significant correlation between (a) patients' therapeutic alliances with the therapist and among themselves (in terms of collaborating on shared goals) and (b) the reported success of therapy. This correlation was statistically significant across the major theoretical approaches and in both couple and family therapy. More split or unbalanced alliances across patients significantly predicted poorer outcomes. Meaning: Taken together, these findings have implications for the kinds of therapist strategies that seem most likely to foster and maintain balanced alliances between partners in a couple or among multiple individuals in a family. Next Steps: Future research should focus on important patient contributions and therapist practices that enhance alliances in conjoint therapy, particularly for family members who are in conflict with one another.

This chapter reviews meta-analytic evidence for the alliance-outcome relation in couple and family therapy (CFT). The authors describe the unique features of CFT alliances and their measurement, followed by case descriptions. A meta-analysis of 48 studies (Ns = 2,568 families, 1,545 couples, and 491 effect sizes) found r = .297. In another analysis with 7 independent samples and 31 effect sizes, the split alliance–outcome association was also significant, r = .316, indicating that the more split or unbalanced the alliance, the poorer the outcome. Moderator analyses showed that alliance–outcome associations did not differ for couple versus family therapy, but correlations were significantly stronger in samples with younger problem children, older adults, proportionally more male youth and adults, and when the families voluntarily sought help (as compared to involuntary or mandated families). The chapter concludes with research-informed strategies for building and sustaining strong alliances in CFT.

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Alliance discrepancies in home-based family treatment: occurrence, development and the therapist's perspective M.J. Welmers-van de Poll , a,b G.

Alliance is a robust contributor to the outcome of adult, youth, and family therapy, but little is known about therapists’ contributions to the alliance in conjoint family treatment. We investigated the predictive value of therapists’ personality, clinical experience and observed alliance building behaviors for mid-treatment alliance as reported by therapists and family members. Participants were 77 parents and 21 youth from 57 families receiving home-based family treatment from 33 therapists. Therapist openness to experience and agreeableness as well as therapists’ in-session engagement and emotional connection behaviors predicted more positive therapists’ and family members’ reports of the alliance. Therapist neuroticism, extraversion and conscientiousness predicted more negative alliance-reports. In-session safety behaviors also predicted more negative alliance-reports, but this finding was only significant for therapists’ and not family members’ reports of the alliance. Clinical experience did not predict quality of alliances. We conclude that training and supervision of family therapists could benefit from focusing on emotional connection with and active engagement of family members in treatment, and from increasing self-awareness of the impact of their personality on alliances with family members.

Alliance at Work – Observation research on the working relationship between care providers and families in intensive outreach family treatment Alliance is an important common factor in the treatment of youth and family problems. When working with multiple family members, building and maintaining strong alliances can be particularly challenging. Alliance at Work (Alliantie in Beeld) is a research project that investigates how alliance processes affect the treatment outcome of IAG, a Dutch homebased family preservation program. Two videotaped IAG sessions of sixty families are analyzed with the System for Observing Family Therapy Alliances. Participants completed the working alliance inventory and treatment outcomes were monitored. Methodological implications and relevance of this observational research project are discussed.