Journal of Clinical Child & Adolescent Psychology

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The Therapeutic Relationship in Child Therapy:

Perspectives of Children and Mothers

Katherine A. DeVet , Young J. Kim , Dominique Charlot-Swilley & Henry T.

Ireys

To cite this article: Katherine A. DeVet , Young J. Kim , Dominique Charlot-Swilley & Henry
T. Ireys (2003) The Therapeutic Relationship in Child Therapy: Perspectives of Children and
Mothers, Journal of Clinical Child & Adolescent Psychology, 32:2, 277-283, DOI: 10.1207/
S15374424JCCP3202_13

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Published online: 07 Jun 2010.

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 Journal of Clinical Child and Adolescent Psychology Copyright © 2003 by
2003, Vol. 32, No. 2, 277–283 Lawrence Erlbaum Associates, Inc.

BRIEF REPORTS

The Therapeutic Relationship in Child Therapy:

Perspectives of Children and Mothers
Katherine A. DeVet, Young J. Kim, and Dominique Charlot-Swilley
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Department of Population and Family Health Sciences, Bloomberg School of Public Health,
Johns Hopkins University
Henry T. Ireys
Mathematica Policy Research, Inc.

Examined qualities of the therapeutic relationship as perceived by low-income chil-

dren who were in treatment for serious emotional disorders and their mothers. Recent
emphasis on engaging families in the treatment of their children highlights the impor-
tance of understanding processes that facilitate therapeutic partnerships. Therapeu-
tic bonds (i.e., the closeness of the relationship to therapist) for both children and
their mothers were assessed. One-hundred fifty-seven families participated. Cross-
sectional analyses indicated that children’s perceptions of closeness with their thera-
pists were associated with their perceptions of closeness with their mothers, their own
age, and welfare status of the family. Maternal therapy bond scores were associated
with mental health services efficacy and breadth of social support.

Despite clinical wisdom that therapeutic relation-
ships in child therapy are important (e.g., Braswell,
1991; Kendall, 1991) and that the therapeutic relation-
ship contributes to treatment outcomes for adults (e.g.,
Horvath & Luborsky, 1993), research on the therapeu-
tic relationship in child therapy has been neglected
(Shirk & Saiz, 1992). Although measures of the thera-
peutic process in child psychotherapy have been devel-
oped recently (Estrada & Russell, 1999; Shirk & Saiz,
1992; Smith-Acuna, Durlak, & Kaspar, 1991), rela-
tively few studies have examined child psychotherapy
processes.
Relationships between parents and their children’s
therapists also have received little empirical attention,
despite the finding that parental involvement in the
child’s therapy is related to therapeutic outcomes (Kaz-
din, 1988; Kendall, 1991; Mendlowitz et al., 1999;
Shirk & Saiz, 1992). Understanding more about the re-
lationship between parents and their children’s thera-
This investigation was supported by Grant MH56995 from the
National Institute of Mental Health. Special thanks are due Miye
Schakne, Wendy Shields, and Diane Sakwa.
Requests for reprints should be sent to Katherine A. DeVet, De-
partment of Population and Family Health Sciences, Bloomberg
School of Public Health, Johns Hopkins University, 624 N. Broad-
way, Baltimore, MD 21205. E-mail: kdevet@jhsph.edu
pists might yield important insights into processes and
outcomes of child therapy. For example, in one recent
study, a strong bond between therapists and parents
was found to increase the likelihood that the child at-
tended therapy consistently and that the family fol-
lowed suggested homework (Diamond, Diamond, &
Liddle, 2000). This study was designed to extend
knowledge of the therapeutic relationship with both
children and their parents.
Research on the therapeutic alliance in both adults
and children has suggested that the relationship is pre-
dictive of therapeutic outcomes, with the participant’s
perception tending to be more predictive of effects than
the therapist’s perception (Horvath & Luborsky, 1993;
Marziali & Alexander, 1991; Shirk & Saiz, 1992). Ad-
ditionally, a recent study has shown that problems with
the therapeutic relationship, more than other factors,
are associated with premature termination of therapy,
preventing clients from receiving potential therapeutic
benefits (Garcia & Weisz, 2002). Thus, the therapeutic
bond is critical to the success of therapy (Orlinsky &
Howard, 1986).
Several researchers have attempted to define what is
meant by the therapeutic relationship (Bordin, 1979;
Saunders, Howard, & Orlinsky, 1989; Shirk & Saiz,
1992). Although their components differ somewhat, all

277
 DEVET, KIM, CHARLOT-SWILLEY, IREYS
of these formulations include the affective quality be-
tween client and therapist as a fundamental ingredient in
the therapeutic relationship. This study focused on this
affective dimension. For our purposes, the terms rela-
tionship, bond, and alliance are used interchangeably.
Various theories have been suggested to explain the
development of the therapeutic bond in children of dif-
ferent ages (see Shirk & Saiz, 1992, for review). At-
tachment theory suggests that the ability to enter into
relationships is dependent on early attachment history.
From this perspective, children’s positive relationships
with parents produce favorable expectations for other
child relationships, whereas adverse parent–child rela-
tionships produce negative expectations for other rela-
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tionships (Rubin, Coplan, Nelson, Cheah, & Lagace-
Seguin, 1999; Shirk & Saiz, 1992). These expectations
can contribute to the development of the therapeutic al-
liance (Frieswyk et al., 1986). Thus, early secure
attachment and current positive relationships with par-
ents are likely to play an important role in the de-
velopment of a strong therapist–child bond.
Social cognitive theory suggests that self-evaluative
and attributional styles are important for the develop-
ment of a positive therapeutic relationship. For example,
if a child does not evaluate him or herself as in need of
behavioral or emotional change, he or she may be less
willing to enter into therapy. Self-evaluative processes
improve with age as children develop more sophisti-
cated cognitive processes and use social comparisons
(Lamb, Hwang, Ketterlinus, & Fracasso, 1999; Shirk &
Saiz, 1992). Given the increase in social cognitive skills
as the child grows, older children may be more likely to
develop positive therapeutic relationships.
Studies of adult client characteristics that contribute
to the formation of the therapeutic bond also have
stressed the importance of quality of social and family
relationships, early parental relations, and psychologi-
cal mindedness (Hilliard, Henry, & Strupp, 2000;
Horvath & Luborsky, 1993; Marziali & Alexander,
1991). In addition, high levels of psychopathology and
stressful life events are likely to impair the quality of
the therapeutic relationship by interfering with avail-
able emotional and social resources and attention to de-
vote to therapy (Horvath & Luborsky, 1993; Marziali
& Alexander, 1991). Thus, poor social relationships,
significant psychological distress, and high life stress
are likely to be associated with unsatisfactory develop-
ment of the therapeutic bond.
Because of the scarcity of previous research in the
area and to generate hypotheses for future studies, we
designed this study as exploratory. We proposed that
for children, their age, relationships with their mothers,
and socioeconomic status would be positively related
to the therapeutic bond, whereas behavior problems
would be negatively related to the therapeutic bond.
For mothers, we examined whether perceived men-
tal health services efficacy, social support, child age,
278
whether she sees her own therapist (yes/no), and so-
cioeconomic status were positively related to the
therapeutic bond between the mother and the child’s
therapist. Also, we expected that child behavior prob-
lems and maternal psychological distress would be
negatively related to maternal therapeutic bond. For
both mothers and children, we used welfare status as a
measure of socioeconomic status. Because previous
studies have not examined the potential impact of race,
we incorporated this variable as well.
Method
This study used data from an ongoing, longitudinal
program evaluation. Potential participants were identi-
fied by agencies providing mental health services to
children between the ages of 9 and 14 years with severe
emotional or behavioral disorders. There were more
than 70 therapists involved in providing treatment for
the children in the sample. An effort was made to re-
cruit every eligible family on clinic or school rosters.
Throughout the article, for ease of reading, we refer to
the parent or guardian as mother. However, this could
mean biological mother, step-mother, foster mother,
aunt, or grandmother.
Therapists or teachers presented an information
packet and release of information form explaining the
research project to eligible mothers. Mothers who
signed the release form received an explanatory tele-
phone call. If they agreed to participate, appointments
were made for two trained interviewers to come to the
family’s home. Data were collected using two simulta-
neous, face-to-face, structured interviews of 90 to 160
min with the mother and 60 min with the child. At the
end of the interview, mothers and children received
payment ($25 and $10 respectively, increased to $50
and $15 during recruitment) as a token of thanks. Each
completed interview was reviewed by one of the inves-
tigators to identify interviewer error or the need to ad-
dress suicide or abuse risk. Informed consent state-
ments were signed by all mothers at the beginning of
the interview; and assent statements were signed by all
children. All procedures were approved by relevant In-
stitutional Review Boards (IRBs).
Four hundred twenty-five release forms were re-
turned from the clinics and schools. Of those returned,
95 (22%) were ineligible (e.g., child out of age range or
not in therapy; mental retardation in the child) or could
not be contacted (e.g., phone disconnected). Fifty-three
(16%) mothers refused to participate either at the re-
cruitment site or during the phone call. Interviews were
scheduled with 20 families (6%) but were unable to be
completed because of multiple no-shows on the part of
the family. Of the 257 interviews (78%) that were com-
pleted, 11 mothers and 17 additional children had to be
deleted because of poor understanding of the interview.
 THE THERAPEUTIC RELATIONSHIP IN CHILD THERAPY

The final sample included 229 mother–child pairs and
17 additional mothers. The decision was made to in-
clude data from the mothers when the child data were
missing because analyses for mothers could still be con-
ducted with data only from the mothers. However, when
data from the mothers were missing, child data were de-
leted because crucial variables were lost. Table 1 pres-
ents descriptive information for the sample. The mean
age for children was 11.2 years (SD = 1.5), and the mean
age for mothers was 40.2 years (SD = 10.08). Overall,
the sample includes predominantly low-income urban
families living in poor neighborhoods with high rates of
violence and few financial resources.
The Therapy Bond Scale (TBS; Shirk & Saiz, 1992)
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the TBS were used for mothers and children. Mothers
who did not meet with their child’s therapist (n = 35)
were not administered the TBS. Internal consistency
for both mothers and children was acceptable in this
sample (α = .86 and .82, respectively). No item, if de-
leted, would have added to the alpha for either the ma-
ternal or child TBS.
The Child’s Report of Parental Acceptance/Rejec-
tion factor (Margolies & Weintraub, 1977) from the
Child’s Report of Parental Behavior (Schaefer, 1965)
was used to assess the child’s perception of the warmth
and closeness of the relationship with the mother. In-
ternal consistency was high (α = .85 to .89; Schwarz,
Barton-Henry, & Pruzinsky, 1985), and 1-week and

was used to measure the child’s perspective of the af- 5-week test–retest reliabilities were found to be ac-
fective nature of the therapeutic relationship. The TBS ceptable (r = .92 and .79, respectively; Margolies &
consists of seven items that are rated by children on a Weintraub, 1977).
4-point Likert-type scale, ranging from 1 (not at all like The Child Behavior Checklist (CBCL; Achenbach,
you) to 4 (very much like you). Items are positively (“I 1991) was used to assess maternal report of child inter-
like my therapist”) or negatively (“I’d rather do other nalizing and externalizing problems, and the Youth
things than meet with my therapist”) worded. Internal Self Report (YSR; Achenbach, 1991) allowed children
consistency reliability was good (α = .72 to .74), and to report on their own internalizing and externalizing
evidence for validity has been provided by correlations problems. Both the CBCL and YSR are standardized
with the child’s collaboration with therapeutic tasks measures, consisting of 112 behavior problem items.
(Shirk & Saiz, 1992). The CBCL and YSR are widely used, have subscales
Because we found no previous research examining that tap externalizing and internalizing behaviors, have
parental relationships with their children’s therapists, good reliability, and have available norms that reflect
we used the TBS in a modified form to measure moth- both age and sex differences. The YSR was used with
ers’ perceptions of their relationships with their chil- the subset of children ages 11 or older (n = 95).
dren’s therapists. Items were reworded to take the Maternal psychosocial resources assessed in this
mother’s perspective (e.g., “I look forward to meeting study included mental health services efficacy and so-
with my child’s therapist”; “I wish my child’s therapist cial support. Maternal mental health services efficacy
would leave me alone.”) Items were rated by mothers was assessed with the Vanderbilt Mental Health Ser-
on a 4-point Likert-type scale, ranging from 1 (strongly vices Efficacy Questionnaire (Bickman, Earl, & Klind-
disagree) to 4 (strongly agree). Thus, parallel forms of worth, 1991). This is a 25-item scale that taps parents’
beliefs that they can participate in activities necessary
for their children’s treatment and that this participation
Table 1. Sample Description will yield positive results. Split-half, alpha, and
N % test–retest reliability are good (.85, .89, and .76, re-
spectively). The Vanderbilt Mental Health Services Ef-
Child sex
ficacy Questionnaire was related to general self-effi-
Male 185 75
Female 61 25 cacy and parental efficacy, as well as with skills,
Welfare status knowledge, and attitudes toward mental health profes-
On welfare 90 36 sionals, providing evidence for validity (Northrup,
Not on welfare 156 63 Bickman, & Heflinger, 1995).
Maternal education
The depression and anxiety subscales of the Psychi-
Less than high school 93 38
High school 95 39 atric Symptom Index (Ilfeld, 1976) were used to mea-
More than high school 57 23 sure maternal psychological distress. The Psychiatric
Missing 1 1 Symptom Index is a 29-item version of the Hopkins
Family composition Symptoms Checklist and has been widely used to mea-
Both biological parents 30 12
sure psychiatric symptoms in adults (e.g., Silver, Ireys,
Mother alone 124 50
Other 91 37 Bauman, & Stein, 1995). The 11-item anxiety scale
Missing 1 1 and the 10-item depression scale were rated by moth-
Child race ers on a 4-point Likert scale, ranging from 0 (never) to
African American 175 71 3 (fairly often). Alpha coefficients for the Psychiatric
White 45 18
Symptom Index anxiety and depression subscales are
Other 26 11
.85 and .81, respectively (Ilfeld, 1976).

279
 DEVET, KIM, CHARLOT-SWILLEY, IREYS
Structured items from previous studies were used
to collect demographic data (family composition, ma-
ternal and child race); socioeconomic status (mater-
nal education, welfare status, perceived financial situ-
ation, and maternal employment); and information
concerning mothers’ own therapy. We assessed
breadth of social support with items that asked moth-
ers if they had someone who could provide specific
types of support. In this study, the child’s race was
dichotomized into White or non-White (including Af-
rican American, Hispanic American, Native Ameri-
can, or other).
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Results
For both children and mothers, bivariate relations
between the TBS and the variables hypothesized to be
related were examined with correlations, t tests, and
analyses of variance. The children’s TBS was related
to welfare status, relationship with mother, and child
age. Children whose mothers were on welfare reported
higher mean bond scores (M = 23.43) than children
whose mothers were not on welfare (M = 21.96; t =
–2.34, p < .05). The children’s TBS was significantly
positively correlated with perceived relationship with
mother (r = .30, p < .001) and negatively correlated
with child age (r = –.25, p < .001). Other variables, in-
cluding maternal therapy bond, maternal education,
family composition, mother-rated internalizing or
externalizing problems, self-rated internalizing or
externalizing problems, and child race and gender,
were not significantly related to the child TBS.
The maternal TBS was positively correlated with
mental health services efficacy (r = .42, p < .001), and
breadth of social support (r = .16, p < .05). No other
variables, including maternal depression, anxiety, wel-
fare status, maternal therapy status, family composi-
tion, child gender, race, or child behavior problems,
were related to maternal TBS scores.
Multivariate analyses were conducted separately for
mothers and children to determine which of the vari-
ables identified in bivariate analyses would contribute to
the prediction of the therapy bond scores and to examine
Table 2. Relative Risk Ratios From Multinomial Logistic Regression Predicting Youth Therapy Bond Scale Scores
RRR
Low therapy bond group
Relationship with mother 0.888
Child age 1.334
Welfare status 0.475
Moderate therapy bond group
Relationship with mother 0.950
Child age 1.384
Welfare status 0.942
Note: RRR = relative risk ratio.
280
the joint effect of variables. Given the somewhat skewed
distribution of the therapy bond scores, we chose to cate-
gorize the scores into low (<21), moderate (21 to 24),
and high (>25) groups, with the high group used as the
reference group in multinomial logistic regression anal-
yses. A multinomial logistic regression can be used
when the dependent variable has more than two catego-
ries. Using one category as a reference group, mul-
tinomial logistic regressions provide a relative risk ratio
(RRR; similar to an odds ratio), which assesses the dif-
ferences between the groups (UCLA Academic Tech-
nology Services, 2002).
For children, relationship with mothers, welfare sta-
tus, and child age were entered into the equation. The
RRRs for the low therapy bond group compared with
the high group were 0.888 for relationship with moth-
ers, 1.334 for child age, and 0.475 for welfare status
(Table 2). All three were significant at the p < .05 level.
The moderate versus high groups were significantly
different only in child’s age with a RRR of 1.384.
A separate multinomial logistic regression analysis
was conducted for the maternal TBS groups. The vari-
ables entered in the model included mental health ser-
vices efficacy and breadth of support. The RRR for the
low therapy bond group compared to the high group
was 0.716 for breadth of support and 0.949 for mental
health efficacy (p < .05; Table 3). Only mental health
efficacy was significantly different for the moderate
versus high group comparison with a RRR of 0.943
(p < .001).
Discussion
Hypotheses derived from previous research in this
area were partially supported by our findings. Chil-
dren’s relationships to mothers were positively associ-
ated with their perceptions of the therapy bond. How-
ever, contrary to our hypotheses, child age was negatively
related to the therapy bond, whereas welfare status was
positively related to the therapeutic relationship. For
mothers, consistent with our prediction, mental health
services efficacy and maternal social support were posi-
tively associated with their relationship with their chil-
dren’s therapists. Contrary to our hypotheses, maternal
Standard Error z Significance
0.026 –4.10 .001
0.152 2.53 .01
0.172 –2.06 .04
0.030 –1.64 .10
0.168 2.67 .01
0.348 –0.16 .87
 THE THERAPEUTIC RELATIONSHIP IN CHILD THERAPY
Table 3. Relative Risk Ratios From Multinomial Logistic Regression Predicting Maternal Therapy Bond Scale Scores
RRR
Low therapy bond group
Breadth of support 0.716
Mental health efficacy 0.949
Moderate therapy bond group
Breadth of support 0.964
Mental health efficacy 0.943
Note: RRR = relative risk ratio.
distress and child emotional or behavioral problems
were not significant predictors of the therapy bond.
As predicted by attachment theory (Shirk & Saiz,
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1992), children’s relationships with their mothers were
positively related to their perceptions of the therapy
bond. Therefore, children who have poor relationships
with their mothers are likely to have difficulty estab-
lishing good relationships with their therapists. In ad-
dition, because children and adolescents are unlikely to
refer themselves for therapy, they may perceive their
mothers as the reason they are in therapy. If they have
poor relationships with their mothers, they may be par-
ticularly resentful of being in counseling, making it
difficult to forge a strong therapeutic bond.
Based on prior studies (mostly with school-age chil-
dren), we had predicted that child age would be associ-
ated positively with the therapeutic bond because as
children mature they may have better insight into their
need for change (Shirk & Saiz, 1992). However, we
found that older children in our sample were less likely
to report close relationships with their therapists com-
pared to younger children. Discrepant findings may re-
sult from samples that vary in children’s ages and men-
tal health status. Engaging adolescents in therapy
poses unique difficulties, including the establishment
of the therapeutic bond. As children grow into adoles-
cence, emerging issues of autonomy and independence
may make them more unwilling to participate in ther-
apy that their mothers or other adults have suggested.
In addition, the presenting problems of school-age
children may be quite different than those of adoles-
cents; such differences may contribute to difficulties
establishing the therapeutic relationship.
Contrary to expectations, welfare status was posi-
tively associated with child therapy bond scores. One
possible explanation is that mothers who are not on
welfare have more difficulty getting to therapy ap-
pointments because of their work schedules. There-
fore, mothers on welfare and their children would have
more consistent contact with therapists, perhaps lead-
ing to better therapeutic relationships. Further exami-
nation of the effects of socioeconomic status in gen-
eral, and welfare status in particular, is needed to
clarify our finding.
Maternal perceptions of their efficacy regarding the
mental health system were associated with mothers’
Standard Error z Significance
0.105 –2.29 .05
0.021 –2.34 .05
0.109 –0.33 .74
0.015 –3.65 .001
therapy bond. It is unknown whether the therapy bond
contributed to feelings of mental health services effi-
cacy or if mental health services efficacy contributed to
the therapy bond. There may be at least a somewhat re-
ciprocal relationship between the two. Longitudinal
studies will be important to try to tease out the causal
relation.
Maternal social support also was related to the ther-
apy bond, but only when comparing mothers who had
low levels of therapy bond and mothers who had high
levels of therapy bond. These findings are consistent
with previous findings that have found the quality of
other social relationships to be important to the es-
tablishment of the therapeutic alliance (Horvath &
Luborsky, 1993).
Surprisingly, child behavior problems were not re-
lated to the therapeutic bond. These findings are simi-
lar to one previous study that found the development of
the therapeutic alliance was not related to the total
problems score of the CBCL but was associated with a
measure of relationship problems (Eltz, Shirk, &
Sarlin, 1995). Additionally, maternal psychological
distress was not associated with the therapeutic rela-
tionship. Characteristics of this sample may have con-
tributed to these results. The uniformly high levels of
life stress in this sample may have obscured a link be-
tween therapeutic bond and maternal psychological
distress. Future studies designed to investigate differ-
ences between previous findings and our results may
provide clarification and insight into the complexities
of the therapeutic relationships in child therapy.
Because this study used data that were collected for
a larger ongoing project that was not designed specifi-
cally to examine the therapeutic relationship, there
were some important variables missing. For example,
duration of therapy and therapist factors are unknown
but may have important implications for the therapeu-
tic alliance (Hilliard et al., 2000). Also unknown is the
timing of the assessment of therapeutic bond in rela-
tion to therapeutic processes. Several studies have
shown that different variables are predictive of the
therapeutic alliance at different points in therapy, the
strength of the alliance varies over the course of ther-
apy, and early and late alliance may have different rela-
tions with outcomes (e.g., Horvath & Luborsky, 1993).
Child maltreatment and social cognition, which were
281
 DEVET, KIM, CHARLOT-SWILLEY, IREYS
not assessed in this study, also have been shown to im-
pact the therapy bond in children (Eltz et al., 1995;
Shirk & Saiz, 1992). Additionally, the data are cross-
sectional so causation is unknown. Further studies with
low-income, minority populations to examine other
variables associated with the therapy bond and to ex-
plore questions raised by this study are vital.
Most previous studies of therapeutic processes have
not focused on low-income, African American popula-
tions. The high residential mobility, chronic stressors,
and a lack of access to mental health services can make
participation in research especially burdensome or dif-
ficult (McLoyd, 1990; Stoneman, Brody, Churchill, &
Winn, 1999). Recruitment of this population can be
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particularly challenging. Our study represents one of
the few to report systematically on therapeutic rela-
tionships in a highly vulnerable population.
Engaging youth and families as partners in all steps
of intervention is a high priority in the recent Surgeon
General’s Report on Children’s Mental Health (De-
partment of Health and Human Services, 2001). Be-
cause previous research suggests that the therapeutic
bond is important for maintenance and success of ther-
apy, this area deserves more empirical attention. Un-
derstanding the therapeutic process, especially in pop-
ulations that pose special difficulties for treatment, is
crucial.
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