Evaluation of the Client-Therapist Relationship in an Emotion Regulation Intervention for Children with Autism Spectrum Disorder
Evidence-based practice (EBP) involves integrating the current best available research literature with clinical expertise and client characteristics, values, and preferences (American Psychological Association, 2005). An understudied yet important facet of EBP is the therapeutic alliance (TA), or collaborative therapist-client working relationship. Across treatment modalities, TA is a predictor of treatment success in both child and adult populations (Horvath & Symonds, 1991; Martin et al., 2000; Wampold et al., 1997). Researchers have described the need to evaluate TA in interventions for children and youth with ASD (Brown et al., 2014). Empirically supported treatments designed to address co-occurring emotional and behavioral problems of children with ASD are emerging; however, relatively little work has been done to examine TA in interventions for this population.
The objective of the current study was to examine the therapist-client relationship and its relation to client satisfaction ratings and child treatment outcomes in a cognitive behavior therapy (CBT) intervention, the Secret Agent Society: Operation Regulation (Beaumont, 2013).
As part of an ongoing randomized waitlist controlled trial, 20 children (19 males) ages 8 to 12 years (M = 9.8; SD = 1.29) with ASD and their parents completed the 10-session CBT intervention and detailed measures of therapeutic alliance. Parents and children completed child ER (Emotion Regulation Checklist (Shields & Cicchetti, 1997; Children’s Emotion Management Scale, Zeman et al., 2010) and psychopathology (Behavior Assessment System for Children, 2nd Edition, Reynolds & Kamphaus, 2004) measures pre- and post-intervention. Two trained coders rated early (Session 2), middle (Session 5), and late (Session 9) therapy sessions using the Therapy Process Observational Coding System–Alliance Scale(McLeod, 2005; McLeod & Weisz, 2005). Coders established excellent reliability (ICC = .95). Parents and children completed post-intervention program satisfaction measures.
Forty-nine unique video-recorded sessions were coded across 20 participants for child-therapist and parent-therapist alliance (ICC = .95). Observational ratings of these alliances were correlated (r = .48, p= .04), with ratings of child-therapist alliance and parent-therapist alliance high across early, middle, and late sessions.
Early session child-therapist alliance was not related to child psychopathology, ER, or satisfaction ratings; however, high early parent-therapist alliance was related to low parent-reported internalizing problems post-intervention (r = -.69, p =.002). High middle session child-therapist alliance was correlated with low externalizing symptoms (r = -.68, p =.004) and emotional lability/negativity (r = -.73, p =.001). High middle session parent-therapist alliance was also correlated with low in externalizing problems (r = -.51, p =.05) and higher child-reported overall coping (r = .61, p =.02). Finally, high late session child-therapist alliance was correlated with child-reported satisfaction with the program (r = .80, p =.001) and child-reported coping (r = .69, p =.003) post-intervention. Late parent-therapist alliance was not correlated with any post-intervention measures (p> .05).
Our study highlights the importance of examining therapeutic relational processes to understand client satisfaction and treatment outcomes of children with ASD. The implications of understanding relational processes on the delivery of empirically supported treatments in this population will be discussed.