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Alliance in Youth Care; research done by the Research Group for Key Factors in Youth Care
Alliantie in jeugdzorg; onderzoek door het lectoraat Werkzame Factoren in de Zorg voor JeugdLinda Rothman, Rinie van Rijsingen & Huub Pijnenburg 1
This article introduces the concept of alliance in youth care. The concept of (therapeutic) alliance originates in adult psychotherapy and related research. Alliance refers to the working relationship between youth care workers and their clients. Within this concept, personal (emotional) and task related components can be discerned. The body of psychotherapy research suggests that a positive alliance is perhaps the most powerful predictor of a positive outcome of the collaboration between clients and care professionals. The question that arises there from is: does this also hold true for youth care? Firstly, this article provides a brief overview of alliance, based on the research in psychotherapy (where the concept was thoroughly analysed). Secondly the article gives an overview of alliance in youth care, researched by the Research Group for Key Factors in Youth Care. It is presented as a vital factor within the conceptual theoretical frame of the Integrative Change Factors (ICF) model for youth care. The concept of the ICF model is followed by a description of the development of the YCAS, an instrument to measure alliance in youth care. In conclusion the article reflects on goals for future research on the concept of alliance, aimed at assessing its importance for youth care provision and at providing professionals with valid tools to boost and uphold their alliance building and monitoring skills.
Keywords: Alliance; Youth Care; Common Factors; Working Relationship; Research
This article focuses on ‘alliance’: The concept of alliance refers to the collaborative aspect of the relationship between psychotherapists or other care professionals and their client(s), in the context of therapy and psychosocial care provision (Pijnenburg, 2010). The notion of alliance or working alliance originates in the context of individual psychotherapy. In accordance with Bordin’s (1979) influential view, most authors – including ourselves – see alliance as a concept consisting of three effective components: (1) agreement between professionals and clients on the goal(s) of their therapeutic collaboration, (2) agreement on the actual tasks which constitute the therapeutic process, required to achieve those goals (task alliance, Green, 2006), and (3) an emotional bond between the two persons, resulting from a positive interpersonal attachment and an environment of trust, acceptance and confidence (emotional alliance, see also Norcross, 2002).
Alliance is one of the focal points of the Research Group for Key Factors in Youth Care at HAN University of Applied Sciences in the Netherlands. Our team focuses its attention on the professional practice of child and family services and youth mental health care (hereafter: ‘youth care’ for short). Furthermore, in this article all professionals who work directly with clients (children, youth or families) in this domain will be referred to as ‘youth care workers’.
One of the goals of this research is to gain more insight into the assessment and quality of alliance between youth care workers and their clients: children, youth and their parents or caretakers. The research group aims to contribute to the further development of knowledge and tools that advance the effective cooperation skills of professionals in youth care. To achieve this, the research group has developed a conceptual model of common and specific (intervention) factors that account for variance in the outcome of youth care provision: the Integrative Change Factors Model. Another way to contribute to the further advancement of knowledge and tools is the development of an instrument called the Youth Care Alliance Scale (YCAS). The purpose of the YCAS is to measure and assess alliance between the youth care worker and the client. The YCAS creates an opportunity to discuss the alliance with the client, in order to use interventions where necessary to strengthen the alliance itself and to stimulate a positive outcome of the care provision. Ultimately, the aim is to implement alliance assessment, monitoring and (feedback-based) optimisation in youth care. To accomplish this, we first seek to gain insight into the origins and development of the concept of alliance in youth care practice by posing such questions as:
What happens to alliance when an agreement between the client and the professional about collaborative goals is not reached or lost?
What happens when one of the partners does not experience an emotional bond or ‘click’ (anymore), or when the two parties face differences, for example: a different view on the approach to the client’s ‘problems’?
To what extent does such lack of alliance pose a problem in terms of the (desired) outcome of the care provision?
The scope of this article is five-fold: first to present the concept of alliance in its origins, from the context of psychotherapy, then to discuss alliance in youth care, present the Integrative Change Factors Model and explore the development of another instrument: the YCAS and discuss the deployment of alliance.
Alliance in Psychotherapy
Therapeutic alliance has been extensively researched in the context of adult psychotherapy. Research in psychotherapy has shown that success in care is not first and foremost achieved through the effectiveness of particular interventions or programs. Rather, treatment efficacy is to a far greater extent accounted for by the quality of the relationship between clients and the therapist (Assey & Lambert, 1999; van Yperen et al., 2010; Pijnenburg, 2010). Therapeutic alliance is a strong predictive indicator of treatment engagement and outcomes.
This leads to the question of what it is that effective therapists do in terms of actions and qualities. An investigation of psychodynamic therapy (Najavits & Strupp, 1994) shows that focussing on positive rather than negative behaviour of clients is effective. Also, treating clients with warmth, showing empathy, and giving affirmation are considered positive contributions. In contrast: belittling, blaming, ignoring, neglecting, attacking and rejecting are considered negative behaviours.
Other common factors
The fact that having a good alliance is the cornerstone of effective therapy does not imply that alliance is the only common or intervention-nonspecific key factor that fosters successful therapy. Personal characteristics of the client and the therapist, the relationship between the two, the chosen method and the context in which it is executed, are all factors that are instrumental in achieving a successful outcome. All of these factors and their interrelations should be studied (Norcross, 2002).
The effects of alliance
Depending on the research cited, the influence of a positive alliance is estimated to be five to seven times larger than the chosen method or technique (Figure 1) (Hubble et al., 2010). Based on a review of the researched literature, Norcross (2010) estimates that the effect size (ES) of alliance is 0.45. This is clearly larger than the effect of the chosen intervention (often 0.20 or less; ranging from .01 to .40). It is striking that there is no correlation between the length of the care trajectory chosen by therapist and client and the power of the alliance. The quality of alliance has a predictive power with regards to the outcome of the care trajectory from as early as the third to fifth contact, at a stage where there is hardly any improvement. This implies that alliance is not the result of a positive outcome, but rather a driving force of it. The development of alliance is not the same for all types of clients or care provision. For example, it is more complicated to build an alliance with (drug) addicts and clients with serious mental health problems, than it is to build an alliance with those without these problems.
Substantial deteriorations in alliance or even ruptures along the way are the rule rather than the exception. A therapist should take the initiative in exploring a client’s reaction on the quality of the alliance, especially when there are subtle indications of alliance ruptures.
Figure 1: Factors for successful therapy outcomes
Sources: Assay & Lambert (1999); Lambert (1992); Wampold (2001)
The diagram points out that extra-therapeutic factors, beside the alliance between a professional and the client, are very relevant to youth care (especially for ambulatory care services), but also to social work and social work contribution. According to Thomas (2006: 204):
‘Extra-therapeutic factors are components in the life and environment of the client that affect the occurrence of change, such as the client’s inner strengths, support system, environment, and chance events. More specific examples of these factors include faith, persistence, supportive family members, community involvement, job, or a crisis situation.’
Therefore, youth care is a dynamic process, as well as the context in which the client is in. This implicates that the professional has to be alert to changing factors in the environment of the client. Whenever needed, the professional has to deal with and adapt to developments such as getting a job or finding a flat.
Alliance in Youth Care
Based on the available research, it is safe to say that alliance in youth care is very similar to alliance in adult (psychodynamic) care. It is important to note that a client’s assessment of alliance is almost without exception a better predictor of the outcome of the care he receives, than assessment of the same by the youth care worker. In youth care, the effects of alliance can manifest themselves in different ways (this is different from alliance in a therapeutic setting). Care or support may be aimed at influencing the behaviour of caregivers. In this case, alliance is important because changes in parental behaviour influence the behaviour of the child. Care or support may also be aimed at influencing the behaviour of the child. In this case alliance is important, because parents play an important role in informing youth care workers of progress, in the practical support and in the continuous positive development in everyday life. An interesting question is how to approach the pairing of a client to a youth care worker when in first instance no real alliance is established, resulting in a decrease of the likelihood of a positive outcome of their collaboration. Care provision centres and care professionals must take this into serious consideration.
Often, professionals in youth care face the challenge of having to form multiple alliances at the same time: with youth, with caregivers, and in their cooperation with other youth care workers (colleagues or professionals from other institutions). Research findings suggest that the differences in alliance between the alliance partners or family members have a predictive power and may lead to termination of contact by the client. For example: the youth care worker suggests that the client behave in a certain way, but the caregivers do not endorse the suggestion of the youth care worker. These differences may also occur in regards to complaints, non-compliance with appointments or the lack of opportunities for interim contact (Kelley et al., 2010). It is imperative that the network of professionals and caregivers share the same view on how to address issues. When they have different opinions, it is still necessary that the cooperation between the partners continue. It is important that issues in the network of professionals will be resolved. This can be accomplished (for example) by appointing a case manager or director.
The Research Group for Key Factors in Youth Care
Having discussed an overview of alliance in its origins, as well as alliance in youth care, we now continue with model development. The Research Group for Key Factors in Youth Care focuses on studying alliance as one of the key common factors in youth care. Various authors (e.g. Duncan et al., 2010) have stressed the need for a conceptual model of common and specific (intervention) factors that account for variance in the outcome of youth care provision. Our research group has attempted to develop such a model: the Integrative Change Factors Model (Figure 2). The model is based on Bordin’s (1979) concept of the revised theory of the therapeutic alliance by Ross, Devon, Polaschek and Ward (2007). The main goal of Integrative Change Factors Model is to facilitate the use of empirical evidence of the power of effective common factors. This model can be used as a guideline in empirical research (see Pijnenburg (2010) for an introduction of this model and a discussion of its various factors).
Figure 2: Integrative Change Factors Model
Source: Barnhoorn, J, et al. (2013).
Alliance is situated at the heart of the model: at the ‘micro’ level of direct (client – professional) interaction. Professionals influence the contact with their clients, through their personal characteristics and communication skills. Aside from this relational dimension, the normative dimension – the expertise of the professional – is also important. Another factor that plays a role are the methodologies used. When a professional has a positive expectation of a particular approach, we speak of allegiance. Clients also bring their personal characteristics, skills and expectations to their interaction with the professional. A precondition for developing a healthy alliance is that clients, in open dialogue with the professional, develop their own theory of change: the right story behind their issues and where these originate, as well as a plan of approach on how to deal with them, which everyone involved, believes in (the change theory). A final component on the micro level is the monitoring of the process and the outcome of the guidance, therapy or treatment. These factors on the micro level are connected to factors on the meso and macro levels.
When we talk about the macro level, we are referring to the developments on a national level. Think of public policies for youth care that influence the efficacy of interventions. Cooperation and coordination between parties on a national level influence the design and results of the youth care. The better the alignment and interplay are, the better the outcome on micro level will be. Education also influences the macro level. It is important that the education of the professionals be tuned to the system of youth care, social work and the practice of mental health care. Once a professional completes his training and enters the actual practice of youth care, his actions directly affect the alliance with his clients. It is impossible to point out all the macro level factors that affect the ICF model, but a final important factor the research group wishes to address is the general image of the youth care in society. The level of trust in the youth care system, which is partly affected by the media, also affects the outcome of the care provided.
The meso level treats the direct surroundings of the client (family, friends, neighbourhood, school and other social institutions). The quality of the social network is a strong predictor of the effectiveness of intervention (Fukkink & Hermanns, 2009). The stronger a network is, the greater the chances are that one can effectively manage their own situation. The support factors in client context may influence the alliance, both on meso and micro level, depending in which context they play a role. Another meso level factor is the ability of the professional to cope with serendipity; to what extent is the professional able to utilise unexpected developments in the environment of the client to the advantage of the change process? In other words: what is the relationship between the professional’s work environment and the common working factors? While there is very little evidence available on this topic, research in the socio-psychological field does suggest that a first impression of the environment is important.
The views of this research group, as well as results of its recent research are reflected in the current national policy vision on youth and education of the Dutch Department of Health (Van Herk et al., 2012), on the agenda of national funding bodies such as the Netherlands organisation for health research and development (ZonMw, 2012) and in Dutch and Flemish manuals for social professionals (Pijnenburg, 2011; Pijnenburg & Van Hattum, 2012). Right now the Research Group for Key Factors in Youth Care is the only research group in the Netherlands that explicitly addresses the general topic of common factors in youth care and in particular the quality and importance of the working relationship between professionals and their clients (and their social network), colleagues and executives.
Youth Care Alliance Scale (YCAS)
Alliance is not an entirely new concept, nor is it something that occurs out of the blue. Most often it develops in a very early stage, somewhere between the 3rd and the 5th therapeutic session. It is necessary to invest in and evaluate or (periodically) monitor alliance (Norcross). If youth care workers want to increase the effectiveness of care, they must develop strategies to monitor and maintain the relationships with their clients. The Research Group for Key Factors in Youth Care has developed an instrument that could help facilitate this process. The instrument has not been validated yet.
The first question that we wanted to examine was whether the concepts of alliance, as formulated in therapeutic settings over the past few decades, are viable in youth care. Do the professionals in youth care use the same concepts as those in therapeutic care? Group interviews with youth care workers in one of the collaborating organisations showed that the words and the concepts they use are very similar to those mentioned in existing literature on alliance in therapeutic settings. These findings motivated and justified the further research into alliance in youth care. The research group set out in search of instruments suitable for assessing alliance in a youth care setting. But first the research group examined what clients expect of youth care workers in regards to alliance.
The study was conducted in a residential youth care facility (Lindenhout) that serves 2000 clients per year. The facility lays in the eastern part of the Netherlands. Lindenhout provides support and guidance to children, young people and their caregivers when needed. The facility offers advice and practical assistance, and also intensive treatment or day care.
A qualitative approach was used in this study to research alliance in youth care and to document the experience from the caregivers. Caregivers that participated in the study were 5 caregivers (parents, both male and female) in different age categories. The participants were at random selected. All interviews were transcribed verbatim. Transcripts were analysed, reviewed and coded, leading to main categories.
The first goal in this part of our on-going research was to translate the concept of alliance in a youth care setting into indicators from a parent’s perspective. The posed question: ‘What do clients expect from youth care workers in regards to alliance?’ The resulting keywords mentioned as important or very important in those interviews are:
(Rens &Vreeman, 2011)
Secondly, the research group sought to translate the concept of alliance in a youth care setting into indicators from a youth care worker’s perspective. Here we posed the question: ‘What do youth care workers find important in the alliance with a client?’
The study was conducted within the same residential youth care facility (Lindenhout).
A qualitative approach was used in this study to research alliance from the perspective of youth care workers. Ten youth care workers participated in the study in different age categories. The participants were at random selected. All interviews were transcribed verbatim. Transcripts were analysed, reviewed and coded leading to main categories.
Results of the study show that it is important that the youth care worker has respect for the youngster, is honest and reliable, acts solution-focused, is a good listener, doesn’t judge, cooperates with the client, that the youth care worker is a worthy discussion partner and mediator for the client, shows transparency, makes expectations clear, exhibits trust, is open, aligns to (fine-tune with) the client, is aware that the client remains in charge and is aware of the importance of first (face to face) contact. (Van Asselt & Bijnen, 2011)
A third goal was to translate the concept of alliance in a youth care setting into indicators from young child’s perspective. As the remaining part of this article focuses on young adults and adolescents, we will not go into detail about our findings in this part of the research. It suffices to say that the results are consistent with the findings in the groups of adults and adolescents.
Search for instruments
With the abovementioned findings in mind we started a search for suitable instruments containing the aspects named by workers and clients and in line with the definition of Bordin (1979). A number of instruments were found, all of them being questionnaires. To properly assess alliance, we found that the use of these instruments often proved cumbersome. For instance, they are not easily applicable because of their length. Most instruments were not primarily designed for use in (clinical or non-clinical) settings in youth care and the context of client-professional dialogue. Various instruments were more relevant to researchers than to clients and youth care workers.1
The most useful one resulted to be the Working Alliance Inventory (Horvath & Greenberg, 1989), which was already translated into Dutch by researchers from Belgium and renamed Werk Alliantie Vragenlijst or Work Alliance Questionnaire (WAV). This WAV has two versions: one for the professional and one for the client. Though shorter than most of the other questionnaires, we did not find the WAV entirely user-friendly, because of the vocabulary used (more geared towards the mental health practice) and due to the fact that the answers must be coded, before a feedback conversation is possible.
The research into existing instruments provided us with a clear image of what a proper and practical tool for assessment of alliance in youth care should look like: relatively short, representing Bordin's aspects of alliance and instantly usable as a tool to discuss the actual alliance with the client. This led to the development of a new instrument in accordance with these terms, namely the Youth Care Alliance Scale: YCAS (in Dutch; de Jeugdzorg AlliantieSchaal, de JAS). The YCAS is the English translation for the Dutch term ‘de JAS’. The instrument is only available in Dutch.
Development of the Youth Care Alliance Scale
The first version of the YCAS focuses on the alliance between professionals and parents. It has a Likert scale; a 5 point answering scale (1= ‘I completely disagree’, 5= ‘I completely agree) and consists of 20 items, divided into 3 sections: 4 items about the agreement on goals, 8 items about the agreement on the way to reach the goals and 8 items about the emotional bond, the ‘click’ between both parties. The selected items are based on the existing literature and research on the topic alliance and the mentioned research at Lindenhout. The items were discussed and reviewed in a focus group of Research Group for Key Factors in Youth Care.
A separate study was conducted to compare the YCAS to the existing instruments and to assess whether it would be a serious contender in the realm of youth care advancement. The YCAS questionnaire was put to the test in a field comparison with the aforementioned WAV. The investigators presented both questionnaires to a group of youth care workers and their clients. We asked five workers and one client of each of them d to fill out the YCAS and we asked five other workers and their clients to fill out the WAV. In addition, the professionals received a short manual outlining how to apply the questionnaires and how to establish a feedback conversation with the scores of both questionnaires at hand.
The study was again conducted within residential youth care facility (Lindenhout).
A qualitative approach was used in this study to research alliance from the perspective of youth care workers and their clients. Ten youth care workers and ten clients participated in the study (both male and female) in different age categories. The participants were at random selected. Five youth care workers and five clients completed the YCAS and five youth care workers and five clients completed the WAV. The youth care workers received a short manual which described how to apply the questionnaires and how to establish a feedback conversation with the scores of both questionnaires at hand. All interviews were transcribed verbatim. Transcripts were analysed, reviewed and coded leading to main categories.
The results were quite positive. In fact, there were positive reactions about both questionnaires and about the procedure. The test subjects all stated the importance of measuring and discussing the alliance.
There was a slight difference in the feedback received about the questionnaires: several subjects found the YCAS more user-friendly than the WAV. It seems that the assumption that a simple lay out on one page and an instant transparent view of the results would be preferred, was indeed correct. In addition to the positive feedback, the subjects also provided recommendations on how to improve the questionnaire, for example to provide more space for elaborations on the given answers. Also, a discussion arose on the best moment to fill out such a questionnaire. However, based on test subjects’ perspective, the general conclusion is that the YCAS is promising and practical in use. From the researcher’s perspective: after proper adjustments, the instrument can be tested in a broader, large-scale study. (Assies et al., 2012).
Further development of the Youth Care Alliance Scale
As mentioned before, instruments to measure the alliance between youth care workers and young children are still in development. And research into a questionnaire to measure alliance with adolescents was yet to be conducted. A proposal was formulated in the spring of 2013 and the research was completed a few months later. The results are worth mentioning in regard to the YCAS. The first intention was to examine the literature on the subject and to choose an instrument that could be possibly be modified for use with adolescents. However, there seemed to be no such instrument available. So it was decided to take the YCAS itself and present this questionnaire to a group of adolescents, to see if they could work with such an instrument. The youngsters had very useful suggestions for modification of the YCAS and to our surprise there were only minor changes to the language used in certain sections. The YCAS was then modified according to this feedback and once again tested in the field: ten adolescents and ten professionals used it with a slightly modified instruction. The idea was to present the questionnaire to five youngsters living in a youth care group and to five youngsters receiving youth care at home. This led to a matching set of social group workers and social home workers, who filled in the questionnaire and had a feedback conversation about the alliance with their clients. The general aim was to fill out the YCAS no earlier than the third working session and no later than the sixth session. This was not always possible, because the research time was limited and not every worker had a client in this stage of the care process. Aside from that, the research went smoothly and the result was, again, promising. Adolescents were very interested in the concept of measuring alliance and they felt they were taken seriously, as their own opinion about the working relationship with their mentor or youth care worker was asked for. It seems that it is still quite uncommon to talk about alliance, with or without the aid of a questionnaire. (Van den Bergh et al., 2013).
The most revealing moment came after this last part of the research. During the discussion of the items of the YCAS (that were changed for the use with adolescents), there was an agreement on the fact that the modified YCAS was not only well suited for adolescents but seemed to be very fitting for adults as well. The language was simplified; an adaptation that especially the verbally less apt parents will surely benefit from. So there is now an updated version of the YCAS, suitable for adults and children 12 years or older. This version will now be validated on a larger scale in the field of youth care.
The purpose of measuring alliance
There are always two goals in measuring a key factor of effective care: a short-term case-oriented goal and a long-term goal to compare groups of clients with the intent to improve the intervention or the work process. The case-oriented goal is to monitor the actual care process with the intent to adjust the approach used when necessary. However, researching alliance alone is not enough; use of the research in practice will have to be guaranteed in order to achieve the desired goals. This assurance begins with actual alliance assessment by the youth care worker. It is important that youth care workers systematically measure alliance and assess it, preferably by means of a questionnaire. Measuring and assessing alliance is only one part of influencing the positive outcome of care. A conversation with the client about the alliance is equally as important, or maybe even more important. If a breakdown occurs, it is important to discuss this with the client and search for a solution. Common factors, especially alliance, are not the only active factors in youth care. More attention is also needed for the specific active factors such as the use of methods.
Merely assessing alliance in practice is also not the end of the line. More research is needed to improve the quality of alliance between the professional and the client. Particularly alliance feedback received from the client and given to the client offers possibilities for improvement of the working alliance. To this end, both the client and the youth care worker can fill out the YCAS and compare and discuss their respective scores, particularly focusing on the items on which they score differently.
One could say that it is the client’s responsibility to be clear and honest in his assessment of the alliance and that the care worker is responsible for the implementation of the given feedback in his approach of the remaining sessions. Ultimately this could mean that, in the case of an irreparable alliance, the care worker may propose to the client to end their collaboration and see to it that the client receive help from a colleague instead (Miller, 2011). The future research of the Research Group for Key Factors in Youth Care will therefore focus on the quality of said feedback dialogue. What are constructive elements in this conversation? Identifying these elements will help us develop an instruction manual and may even lead to the development of a brief training program for youth care professionals to practice, through role play for example, and learn how to effectively foster alliance.
The YCAS looks promising. Monitoring alliance in an on-going youth care process and applying the YCAS in various youth care settings, will help us gather data for the validation of the questionnaire.
The above described research, executed by students, was limited in scale. The number of participants is limited and comes mostly from one youth care organisation (Lindenhout). The research and development of the YCAS is motivated by a strong need from the youth care institution itself to search for ways to monitor and improve the working relationship between youth care workers and their clients. Until now the concept of alliance and its definition by Bordin, has led to the development of the YCAS, and is helpful to reach this goal.
Importance of extra therapeutic factors
Another influencing factor in youth care and social work are the extra therapeutic factors (figure 1). Van Yperen (2010) writes that extra therapeutic factors, true new methodologies of guidance, come within the scope of care. For example true multisystem and multimodal approaches professionals now have the ability to influence the extra therapeutic factors. The interesting question is whether it is possible to provide the client with methods and techniques that support the opportunity to strengthen the control of the client himself. This will affect the results of care. This can contribute to the empowerment of the client: it makes the client less dependent on the professional. Possibly this will affect the importance of professionals, but this is less important. However, the total arsenal of good methodologies will be extended that provide professionals the do’s and dont’s of certain problems and gives clients tools to activate self motivation and will strengthen the control of the client.
Alliance in social work is not something that takes place in a therapeutic, clinical setting. The context is complex and dynamic, the environment is never idle and many changes occur. It is not an environment that can be controlled easily. The context is very different from the context of the clinical, therapeutic setting were the alliance is only made with the user. In addition, the social worker has to deal with various actors that are involved in the life and guidance of the client. The social worker has to align with all these actors, for example with the family of the client, chain partners and other stakeholders such as an employer. All these factors are different from the context of the therapeutic setting (where the origin of the concept alliance lies). The context is complicated and complex. It is important that the social worker is aware of the complexity and acts by: clear communication with the client, but also with the various actors involved in the guidance, make clear agreements with all parties, to be clear and act transparently and work well together with relevant actors.
Cooperation with actors often takes the form of a professional network around the client. Again, it is important that the network of professionals and caregivers share the same view on how to address issues and that issues will be resolved by, for example, appointing a case manager or director.
The context of youth care is very similar to the context of social work. So the facts, as written above, also held for youth care. In youth care there is one aspect that is different from the context of social work. In youth care clients are underage, which makes the context a little bit different. The youth care worker puts the needs of the youngster first. This sort of different types of contexts effects the alliance with a client. It is different for a professional to align with different kinds of target groups. With some target groups it is easier to align then with other target groups. For example: it is harder to form a qualitative good alliance with addicted drug users.
Alliance is needed!
It is clear that alliance is important in youth care to influence a positive outcome of the care provided. The origins of alliance lie in therapeutic settings, but it should also be addressed in youth care (where it is not being addressed yet). The responsibility to address alliance lies directly with the care professional himself (on a micro level). The professional is in the position to directly influence alliance, discuss the alliance with the client and colleagues and to act immediately when a breakdown occurs. The youth care organisation should facilitate the professional to monitor alliance (meso level). For instance by using a questionnaire suitable for the target group. But even on the meso level it is again the professional who should act on alliance (for instance by properly reacting to serendipity) by discussing it with the client. And finally, further research and cooperation between institutions is necessary to influence alliance on a macro level. Research on macro level outcomes can be compared. By comparing outcomes, the quality of measuring, assessing and improving alliance can be expanded and thus ultimately influence a positive outcome of the youth care provided.
 A few examples of available instruments: Penn Helping Alliance Questionnaire (Alexander & Luborsky, 1986), Agnew Relationship Measure, Vanderbilt Scales (Strupp, Butler & Rosser, 1988), California Alliance Scales (Gaston et al., 1991), Working Alliance Inventory (Horvath & Greenberg, 1989; Duncan et al., 1989), Therapeutic Bond Scales (Saunders, Howard, & Orlinsky, 1989).
Alexander, L.B. & Luborsky, L. (1986) ‘The Penn Helping Alliance Scales’, in The psychotherapeutic Process: a research handbook, eds. L.S. Greenberg & W.M. Pinsof, pp. 325–366, Guilford, New York.
Assies, N., Bremer, A., Groot Kormelink, I., & Reulink, L. (2012) Klikt het? Een kwalitatief onderzoek naar de gebruiksvriendelijkheid van twee meetinstrumenten om de alliantie tussen ambulant hulpverlener en client in kaart te brengen, Hogeschool van Arnhem en Nijmegen.
Asselt, A. van, & Bijnen, S.H.E. (2011) De kracht van passende hulpverlening. Onderzoek binnen Lindenhout naar alliantie en de visie van de ambulante hulpverlener, Hogeschool van Arnhem en Nijmegen.
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1 Correspondence to: Linda Rothman, HAN University of Applied Sciences, Key Factors in Youth Care research group, PO Box 6960, 6503 GL Nijmegen – NL, Tel.: +31 24 353 05 65, Email: ; Rinie van Rijsingen, HAN University of Applied Sciences, Key Factors in Youth Care, research group, PO Box 6960, 6503 GL Nijmegen – NL, Tel.: +31 24 353 05 65, Email: ;Huub Pijnenburg, HAN University of Applied Sciences, Key Factors in Youth Care research group, PO Box 6960, 6503 GL Nijmegen – NL, Tel.: +31 24 353 05 65, Email: