Understanding Mother-Therapist Working Alliance in the Parenting-STAIR Open Pilot Trial: The Role of Micro and Macro-Level Factors

Background: Mother-therapist working alliance is essential for the success of mental health interventions delivered in the context of the child welfare system. Mothers’ individual characteristics and past experiences may influence the development of a therapeutic working alliance with clinicians within these programs. However, the quality of the working alliance has not been thoroughly examined in many intervention studies, particularly in the child welfare context, in which parents may feel pressure to attend services and are concerned about the potential negative consequences of child welfare surveillance. Grounded in the ecological model, this study explores how mothers’ characteristics—at both the micro and macro levels—shape their working alliance with therapists, using both mother and therapist perspectives. The study is conducted within an open pilot trial of the Parenting-STAIR (PSTAIR) program, a trauma-focused parenting intervention for mothers and their young children, which aims to improve maternal mental health, parenting skills, and child well-being among families involved in the child welfare system.

Methods: Data were collected from 112 mothers who participated in an open trial of Parenting-STAIR. Eligible participants endorsed trauma at intake and were referred by four child welfare preventive service agencies. Mothers were informed participation was voluntary and would not affect their existing preventive services or their child welfare case. Independent variables included micro level factors (e.g., trauma history) and macro level factors (e.g., involvement with foster care system). Dependent variable was working alliance, was measured separately for mothers and therapists using WAI-S. Participating mothers ranged from 18 to 52 years ago (M = 32.6, SD = 6.5). Multiple linear regression analyses were conducted to investigate the association of individual-level factors and system-level factors with mother-therapist working alliance outcomes.

Results: 60 mothers and their therapists completed the working alliance assessment at week 10, reflecting their experiences in the working alliance. Mothers reported a mean WAI-S score of 70.6 (SD = 4.6), while therapists reported a mean score of 68.7 (SD = 5.3). Multiple linear regression analyses revealed that employment status was negatively associated with mother-reported working alliance (b = -0.29, p < .05). Specifically, employed mothers reported lower working alliance compared to unemployed mothers. Additionally, mothers' history of involvement in the foster care system was negatively associated with therapist-reported working alliance (b = -0.36, p < .05). Therapists rated mothers with prior foster care involvement as having lower working alliance compared to mothers without such a history.

Conclusions: These findings suggest that both micro and macro-level factors significantly influence the quality of the mother-therapist working alliance and that these effects differ from the perspectives of mothers and therapists. For example, mothers who are employed may perceive lower working alliance compared to unemployed mothers due to possible additional employment responsibilities. Conversely, therapists might experience difficulties engaging mothers with prior negative interactions with the foster care system, even within voluntary intervention settings. Understanding mother-therapist working alliance is not a uniform experience, clinicians should consider how personal identities and prior history with systems impact the working alliance, particularly in the child welfare system context.