Child, Caregiver, and Therapist Perspectives on Therapeutic Alliance in Usual Care Child Psychotherapy

The primary aim of this exploratory study was to examine the stability and cross-informant agreement of child and caregiver alliance across 16 months of psychotherapy, using multiple informants on alliance.

Therapists tended to rate alliance lower than children and caregivers. Picture: Adobe Stock/posed by models
Therapists tended to rate alliance lower than children and caregivers. Picture: Adobe Stock/posed by models

A secondary aim was to examine baseline demographic and clinical predictors of greater alliance and different alliance trajectories over time.

  • Report: Child, Caregiver, and Therapist Perspectives on Therapeutic Alliance in Usual Care Child Psychotherapy
  • Authors: Erin C. Accurso and Ann F. Garland, Psychological Assessment (2016)

The most common definition of therapeutic alliance makes reference to the development of an affective bond, agreement on tasks, and agreement on goals (Bordin, 1979). In child psychotherapy, therapeutic alliance has been strongly associated with improved parenting, reductions in the child’s symptomatology and improved family functioning. However, the relation between alliance and outcome appears to be less clear when patients are treated with non-specific treatments more characteristic of usual care, compared with empirically supported treatments.

Therapeutic alliance in child psychotherapy is complicated by multiple relationships – the child-therapist relationship (referred to as child alliance) and the caregiver-therapist relationship (referred to as caregiver alliance) – and multiple perspectives on those relationships.

In addition, few studies have utilised repeated assessment, so very little is known about the stability of therapeutic alliance across treatment, despite its importance in understanding the relation between alliance and outcomes (McLeod, 2011). Nevertheless, several studies have found patterns of increased alliance over time in child outpatient treatment.

The study

This study utilised data from the large Practice and Research: Advancing Collaboration (PRAC) study from the US, which examined usual care psychotherapy processes and outcomes in a representative sample of children with disruptive behaviour problems. Therapists and their patients were recruited from six clinics, which represented the largest contractors for community-based publicly funded outpatient clinical care for children in one of the largest counties in the US.

The sample included 209 children with disruptive behaviour problems and their primary caregiver who contacted one of the six community-based publicly funded clinics in San Diego County to initiate outpatient mental health services.

This sample included 85 therapists practicing in six community-based clinics.

Descriptive data on children, parents, and therapists were collected during in-person baseline interviews. Follow-up interviews were conducted by phone after four, eight, 12 and 16 months, during which child and caregiver therapeutic alliance were assessed.

Children, caregivers, and therapists were asked to report on current therapeutic alliance, or if they recently terminated psychotherapy, to retrospectively report on therapeutic alliance while they were active in treatment.

Child alliance was measured using the therapeutic alliance scale for children, which includes 12 items rated from one (not true) to four (very much true) by children and therapists, with scores ranging from 12 to 48. There is a separate parallel scale for caregivers and parents.


All 209 families were active in treatment at four months, 141 (67.5 per cent) were active at eight months, 100 (47.8 per cent) at 12 months, and 61 (29.2 per cent) at 16 months. Data were considered “missing” when a child and/or caregiver was lost to follow-up despite being actively engaged in treatment.

Temporal stability of therapeutic alliance

Child and caregiver alliance were relatively high across time and informants. Initial inspection of change over time indicated minimal variability across child-reported and therapist-reported child alliance, as well as caregiver-reported and therapist-reported caregiver alliance. Both children and caregivers perceived their alliance as stable over time. In contrast, therapists perceived small but significant deteriorations in child alliance over time but a stable pattern of alliance with caregivers.

There was moderate consistency between child and caregiver reports of their respective alliance with the therapist as well as between child-reported child alliance and therapist-reported caregiver alliance. There was also moderate consistency between therapist-reported child alliance and caregiver-reported caregiver alliance and between therapist-reported child alliance and therapist-reported caregiver alliance.

Child alliance

Results indicated that therapist-reported child alliance improved over time for girls but remained stable in boys, and that alliance improved for children with anxiety disorders but remained stable in those without. There were no significant predictors of child-reported child alliance.

Caregiver alliance

Two separate multivariable models were run for caregiver report caregiver alliance (including caregiver race/ethnicity and therapist experience) and therapist report caregiver alliance (including caregiver sex, caregiver race/ethnicity, and therapist experience). For caregiver-reported alliance, results indicated that non-Hispanic white caregivers perceived alliance to start high and improve less, while caregivers of other races/ethnicity perceived alliance to start lower but improve more across time. Caregivers also perceived a stronger alliance overall with therapists who had less experience.


Overall, children and caregivers tended to report the most stable alliance. Therapists, on the other hand, consistently rated the alliance lower than clients did, and even reported deteriorations over time for child alliance.

This study was unable to identify factors that predicted child-reported alliance, but several factors emerged as predictors of therapist-reported child alliance, including child gender and anxiety disorder diagnosis.

In contrast, caregiver-reported caregiver alliance was predicted by caregiver race/ethnicity and therapist years of experience, but there were only trend-level predictors of therapist-reported caregiver alliance.

These findings revealed that clients generally perceive strong and stable alliances with their therapist, but that therapists may underestimate the extent to which families feel allied with them. Anecdotally, interactions with therapist participants suggest that the alliance is highly valued and sometimes prioritised more highly than therapeutic tasks. Therefore, therapists may be highly sensitive to perceived ruptures in the alliance or highly perceptive of actual caregiver or child dissatisfaction that is expressed in a subtle manner, about which clients may be less aware or fail to report. Therapists may also have exceptionally high expectations for the quality of the alliance and therefore be less susceptible to ceiling effects. Alternatively, therapists may be less aware of alliance quality given that they received relatively little explicit feedback on alliance. Indeed, although the client therapeutic relationship was addressed in almost one fifth of psychotherapy sessions, but most instances were fleeting, with only one per cent considered to be “high-intensity”.

In addition, several factors influenced caregivers’ and therapists’ perceptions of the alliance. For child alliance, therapists perceived significant improvements over time in child alliance with girls and children with anxiety disorders, while alliance with boys and those without anxiety disorders remained stable. This is in keeping with prior research in finding improvements in alliance for children with anxiety (Creed & Kendall, 2005) or greater overall alliance in children with greater anxiety (Chu, Skriner, & Zandberg, 2013). For caregiver alliance, non-Hispanic white caregivers perceived alliance to start high and improve less, while those of other races/ethnicity perceived alliance to start lower but improve more across time. It is possible that this pattern could be the result of initially perceived mistrust or misunderstanding that improves over time.

Caregivers also reported an overall stronger alliance with therapists who had less experience. This finding might be due in part to therapist burn-out, such that less experienced therapists might have been more energetic and eager to build new therapeutic alliances than therapists who had seen many clients/families over the years and who were potentially experiencing burn-out.

In contrast, there was a trend-level interaction such that therapists with more experience perceived caregiver alliance as increasing over time, while those with lesser experience perceived alliance as stable. While not statistically significant, this trend suggests that more experienced therapists may overestimate their ability to develop a stronger caregiver alliance over time.

Implications for practice

  • This study found that early alliance strength did not differ between families who terminated treatment early and those who received long-term treatment. This is in direct contrast to previous efficacy studies in which poorer child and caregiver alliance predict treatment dropout.
  • Agreement between children, caregivers, and therapists on alliance was remarkably high in this sample, nevertheless, therapist reports on alliance were more variable over time and differed from client reports.
  • Therapists tended to rate alliance lower than children and caregivers, and it is possible that specifically requesting feedback on the therapeutic relationship from patients may be helpful to therapists.
  • Less-experienced therapists were more effective in building stronger caregiver alliances than more experienced therapists. Also, less-experienced therapists perceived alliance more accurately (in comparison to caregiver reports) than more experienced therapists. This would suggest that more-experienced therapists might benefit more from explicitly requesting caregiver feedback on the therapeutic process.

Read more in CYP Now's Therapeutic Care Special Report

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