Meta-Analysis of the Prospective Relation Between Alliance and Outcome in Child and Adolescent Psychotherapy

In the youth treatment literature, the alliance has been defined and measured as a consensual or collaborative bond. In this article, we review varied definitions of the alliance, enumerate its frequent measures, and present clinical examples. We provide a meta-analytic review on the relation between the therapeutic alliance and treatment outcome in child and adolescent psychotherapy. In particular, this review only includes prospective studies of youth therapy that used an explicit measure of alliance. The meta-analysis of 28 studies revealed a weighted random effect size of r = .19 (k = 28, N = 2419, p < .01, 95% confidence interval [.13, .25]), which is a small to medium effect (equivalent to d = 0.39) consistent with the adult alliance literature and with prior youth meta-analyses. Given that a medium-large amount of heterogeneity was observed in effect sizes (I2 = 64.19%), theory- and method-based moderators were examined. Multiple moderators of the alliance-outcome association were found, including diagnosis class, type of therapy, study design (randomized controlled trials [RCT] vs. nonrandomized trials [non-RCT]), and treatment setting (inpatient vs. outpatient). Research limitations, patient contributions, and diversity considerations follow. The article concludes with research-informed practices for building and maintaining the therapeutic alliance with youth. Clinical Impact Statement Although many youth treatments have been found effective, less is known about treatment processes that may explain variability in treatment outcomes. Question: This study examined the strength of the correlation between the alliance and youth treatment outcome. Findings: This meta-analysis showed that the therapeutic alliance has a small to medium association to outcome that varies depending upon diagnosis, type of therapy, study design, and treatment setting. Meaning: Alliance formation and maintenance over the course of treatment has the potential to aid clinicians in achieving positive outcomes in youth psychotherapy across disorders. Next Steps: To investigate the effects on the alliance and treatment outcome of clinicians attending to youth and parent characteristics and their own behaviors when attempting to engage them in treatment.