Examining Therapeutic Alliance in an Emotion Regulation Intervention for Children with Autism Spectrum Disorder

Background: Therapeutic alliance (TA) is an important component of treatment success. Much of what we know about this process is rooted in adult psychotherapy research and for typically developing individuals. Less is understood about TA in child psychotherapy, and even fewer studies examine alliance with children with ASD. An understanding of TA in this population and how it relates to other treatment processes and outcomes is needed.

Objectives: The goal of the current study was to examine relations between TA and other process and outcome measures in a trial of cognitive behavior therapy (CBT) for children with ASD. Our objectives were to examine: (1) child- and parent-therapist alliances using a behavioral coding scheme, and (2) relations between behavioral measures of TA and therapist-reported TA, client satisfaction ratings, treatment adherence, and changes in emotion regulation.

Methods: As part of an ongoing trial, 13 males ages 8.3 to 12.8 years (M = 10.3; SD = 1.2) with ASD and their parents completed 10 CBT sessions to improve emotion regulation. Parents and children reported on children’s emotion regulation before and after the intervention, using the Emotion Regulation Checklist (Shields & Cicchetti, 1997) and the Children’s Emotion Management Scale (Zeman et al., 2010; Zeman et al., 2001). At each session, parents and children completed treatment satisfaction measures, and therapists reported on treatment adherence and on their degree of TA with children and parents. Two trained coders rated video recorded therapy sessions using the Therapy Process Observational Coding System–Alliance Scale(McLeod & Weisz, 2005). Coders established excellent reliability (ICC = .95).

Results: To date, 36 unique sessions have been coded across 13 participants for child-therapist and parent-therapist alliance. Overall behavioral ratings of these alliances were correlated (r = .61, p = .037). Ratings of child-therapist alliance were high across early (M = 35.7, SD = 7.62), middle (M = 36.2, SD = 6.31), and late sessions (M = 34.5, SD = 8.86). Similar patterns were found for parent-therapist alliances (M = 39.0; SD = 6.28; M = 39.7; SD = 6.06; M = 39.2; SD = 5.59, respectively). Mean behavioral ratings of child-therapist alliance across the three sessions were correlated with overall homework completion (r = .59, p = .03) and therapist-reported TA across all sessions (r = .76, p = .002). Mean behavioral ratings of parent-therapist alliance were correlated with mean therapist-reported TA (r = .77, p = .004) across all sessions. High overall child satisfaction was correlated with decreases in child-reported emotion dysregulation (r = -.58, p = .046). High mid-therapy behavioral ratings of child-therapist alliance were correlated with improvements in child emotional lability and negativity (mood swings, dysregulated negative affect) (r = .79, p= .002).

Conclusions: Preliminary findings suggest a concordance between behavioral and therapist-reported ratings of relational processes in a treatment study for children with ASD, and relations between TA ratings and treatment adherence and parent-reported improvements in emotion regulation. These findings have implications for future investigations of therapy processes that may mediate treatment outcomes in this population.