Role and Predictors of Therapeutic Alliance in a Parent-Mediated Intervention for Autism

Background: Therapeutic alliance is a measure of the quality of the working relationship between therapist and client. In psychiatry, meta-analyses have shown a small but consistent relationship between quality of alliance and outcome for both adult (Horvath, Del Re et al. 2011) and child/youth clients (Shirk, Karver et al. 2011), and a range of factors have been shown to associate with the quality of alliance. However, therapeutic alliance has been little researched in the context of parent-mediated interventions for children with autism.

Objectives: To investigate the relationship between parent-therapist alliance and a range of baseline and process variables, and the role of alliance as a post-randomisation effect modifier on parent and child outcomes, in a parent mediated intervention for autism.

Methods: Therapeutic alliance was rated at three time points by 77 parents and 6 therapists participating in the Pre-School Autism Communication Trial (Green, Charman et al. 2010). This was a randomised control trial of a parent-mediated intervention for autism (Pre-school Autism Communication Therapy; PACT), compared against treatment as usual (TAU). Baseline variables comprise parent demographic variables, parent causal belief variables, and an average therapist fidelity variable. Process variables comprise parent 'Expression' and therapist 'Integration' of parent perspectives, measured on the Parent Perspectives Coding Scheme (PPCS), developed specifically for the study. 120 sessions from a purposive high-low parent-rated alliance subsample of 20 cases were coded on the PPCS. Since alliance is not measurable in the TAU arm, we use significant predictors of alliance to predict the ‘counterfactual alliance’ that would have been observed in the PACT arm for those randomised to TAU. This forms latent classes of alliance, and we compare outcomes, including measures of parent synchrony, child initiations and symptoms, between PACT and TAU within each of these latent classes.

Results: Parent-rated and therapist-rated alliance did not correlate. Parents who cited MMR as a possible cause of autism in their child rated the alliance lower than those who did not (p<.05) and parents with no post-16 qualifications rated the alliance higher (p<.05); these two variables were independent. A multiple regression model including the two variables in a single step explained 18.3% of variance in parent-rated alliance (Table 1). PPCS Expression and Integration scores were higher in the high parent-rated alliance group but the difference was non-significant. Therapist-rated alliance associated positively with therapist fidelity (p<.01) and with PPCS Expression and Integration variables (p<.01). A multiple regression model containing fidelity, expression and integration explained 58.8% of variance in therapist-rated alliance (Table 2). The analysis of alliance and treatment effects is underway and results will be included in the presentation.

Conclusions: Therapists should be aware that parents may rate the alliance differently from themselves and that different factors associate with their ratings. Parents’ causal beliefs and level of education may influence their ratings of alliance in specific interventions. In keeping with alliance theory, open discussion of disagreement may improve alliance in these cases, especially where the parents’ views on causal beliefs are unlikely to be shared by the therapist.